Medicare

The U.S. government’s 5-Star ratings of the nations nursing homes are in!

While these results are not as glamorous as the Oscars or the Grammys… okay, they are not glamorous at all, but they are significantly more meaningful than entertainment awards, and they affect more of us much more directly. Currently, about 7.5% of Americans currently live in nursing homes. With the current trends in costs of care, health concerns, and the number of aging Baby Boomers, it has been estimated that about 11 million people will be likely to require assistance in old age within the next 10 to 20 years. That makes it essential that we understand what makes a “good” nursing home or a “bad” nursing home, and how to find the good ones.

Every year the Centers for Medicare and Medicaid Services (CMS) publish the results of their 5-Star Quality Ratings of nursing homes. The Five-Star Quality Rating System was created to help consumers, their families, and caregivers compare nursing homes more easily, and help identify areas about which you may want to ask questions. Nursing home ratings are taken from three sources of data:

• Health Inspections. Onsite visits by a team of trained inspectors who check on the quality of care, inspect medical records, and talk with residents about their care. Inspectors also make sure that the nursing home meets federal quality processes.
• Staffing. This rating looks at the overall number of staff compared to the number of residents…as well as how many of the staff are trained nurses.
• Quality Measures. This measure rates how well a nursing home performs on 10 important aspects of care, such as how well the nursing home prevents and treats skin ulcers, and how well residents are helped in eating and dressing. While this sounds like a valuable measure, the data for Quality Measures are self-reported by the nursing home staff. This makes it the least objective measure, and the most likely to be inappropriately high.

Each of these areas is individually rated, and then these three ratings are combined to calculate an Overall Rating.

The lowest overall rating is awarded to homes “much below average” compared with others in their state, according to CMS. Among problems that can drop a rating: consistently dirty equipment and linens, mistreatment and unlicensed caregivers or specialists.

How to Choose a Good Nursing Home

USA TODAY Analyzes Ratings

The CMS Nursing Home Compare data only list the most recent star ratings, but it doesn’t provide a history for consumers. Now, USA TODAY prices an analysis of the ratings for more than 15,000 nursing homes over the past 3 years. Among their findings:

• Quality improved. There was a 5% decrease in the number of nursing homes with 1- or 2-star ratings; and there was a 5% increase in the number of 4- and 5-star rated facilities.
• Some of the worst stay bad. 564 nursing homes received 1-star ratings in each of the rating periods during the past three years.
• Two-thirds of these low-performing facilities are for-profit organizations.

Here’s how to see specific nursing home ratings from the past three years:

• Go to the USA TODAY ratings page here:  USA TODAY Nursing Home Ratings
• On the upper right corner of the chart at the top of the page, enter the state you would like to search.
• On the lower right side of the chart, you can narrow your search by entering a specific term, which can include a city name, part of the name of the nursing home, a street name, etc.
• To see a comparison of all three years’ ratings, click the “+” sign to the left of the nursing home name and address.

ADDITIONAL RESOURCES

USA TODAY article: Fewer seniors live in nursing homes

To see the full reports AND to search for specific nursing homes by name or location, see the Nursing Home Compare page here: Nursing Home Compare

To see the HensonFuerst video about how to choose a good nursing home, click here: How to Choose a Good Nursing Home (and Avoid the Bad Ones)

Here’s a good news story:

The health-care overall championed by President Barack Obama’s administration has saved Medicare recipients about $1.5 billion since it went into effect in January 2011. This amounts to an average savings benefit to the elderly of about $569 per person.

According to a story on Bloomberg.com:

“Millions of Americans are receiving free preventive services and getting cheaper prescription drugs” because of the health law, said Marilyn Tavenner, the acting CMS [Centers for Medicare and Medicaid Services] administrator, in the statement.

The drug discounts apply to Medicare recipients who reach a coverage gap in the program’s prescription medicine plans called the “donut hole.” The law requires drugmakers to provide a 50 percent discount to people in the gap until they spend $4,550 a year, after which the government covers almost all drug costs.

So far, so good. I want to remain optimistic that these kinds of savings will continue, but there’s a saying:  What goes down, must go back up. Or something like that.

To read the full article, click here:  Bloomberg.com

In The New York Times, reporter Jane Gross wrote a fascinating opinion piece about Medicare. She calls it the “dirty little secret of health care in America”:  That while we assume that Medicare provides universal health care coverage for the elderly, what Medicare actually covers isn’t what recipients want or actually need.

With all the advances in medicine, much of the medical care provided to the elderly today are dangerous, pointless, and expensive. As Jane Gross writes:

Of course, some may actually want everything medical science has to offer. But overwhelmingly, I’ve concluded in a decade of studying America’s elderly, it is fee-for-service doctors and Big Pharma who stand to gain the most, and adult children, with too much emotion and too little information, driving those decisions.

Researchers have discovered that some “standard” treatments are both useless and harmful. For example, feeding tubes cause infections, nausea, vomiting, and agitation…but rarely prolong life. Frail elderly patients who have abdominal surgery, gall bladder surgery, or joint replacements, experience  complications…and often require placement in nursing homes.

Medicare pays for all those hazardous treatments. However, Medicare does not typically pay for long-term care in a supervised, safe place for frail or demented old people, or for home aides to help with shopping, transportation, bathing and using the toilet. Ms. Gross continues her story:

In the case of my mother, who died at 88 in 2003, room and board in various assisted living communities, at $2,000 to $3,500 a month for seven years, was not paid for by Medicare. Yet neurosurgery, which I later learned was not expected to be effective in her case, was fully reimbursed, along with two weeks of in-patient care. Her stay of two years at a nursing home, at $14,000 a month (yes, $14,000) was also not paid for by Medicare. Nor were the additional home health aides she needed because of staffing issues. Or the electric wheelchair after strokes had paralyzed all but the finger that operated the joy stick. Or the gizmo with voice commands so she could tell the staff what she needed after her speech was gone.

She paid for the room. My brother and I paid for the private aides and bought her the chair and the “talking board.” What would her life have been like without the skilled care she required and the ability to get around her floor and communicate her needs? I shudder to think. But none of this was Medicare’s responsibility.

Yet Medicare would pay for “heroic” care for a woman who was dying of old age, not a disease that could be treated: Diagnostic tests. All manner of surgery. Expensive medications. Trips to the emergency room or the hospital — had she not refused all of them, in the last year of her life. So, in less than a decade, by my low-ball estimate, my mother spent $500,000 of her own money and uncalculated sums from her two children before winding up what she considered, with shame, “a welfare queen.”

Did you catch that last bit? Half a million dollars?

If you think that’s not in your parents’ future (or your own future), consider that 70 percent of the elderly will need extended care before they die. It would be enormously helpful if Medicare would pay for the care that older patients actually need.

That’s the dirty little secret. That while we count on Medicare to help us keep up with medical care in our golden years, what it actually does is pay for mostly pointless procedures. The actual care falls to families, until all resources are drained, relationships are strained, and adult children lose their retirement savings.

This article scared me. This is one secret that’s not good for anyone.

To read the full article in The New York Times, click here:  How Medicare Fails the Elderly

The New York Times published an eye-opening article about how some antipsychotic drugs given to the elderly are dangerous, and even potentially lethal.

Nearly one in seven elderly nursing home residents, nearly all of them with dementia, are given powerful atypical antipsychotic drugs even though the medicines increase the risks of death and are not approved for such treatments, a government audit found.

More than half of the antipsychotics paid for by the federal Medicare program in the first half of 2007 were “erroneous,” the audit found, costing the program $116 million for those six months.

So…the nursing home residents are being given toxic medications, families and caregivers are duped into believing the pharmaceuticals are of more benefit than they are, and taxpayers are being fleeced to the tune of more than $225 million per year. It’s unconscionable. For some pharmaceutical companies, though, it seems to be business as usual.

Many of the toxic medications are specifically and, according to the article, illegally marketed for use by the elderly. Television commercials for the drug Abilify, for example, show a middle-aged woman taking care of her elderly mother, and talking about how she wants to do everything possible to help her mother from losing more of her memory to dementia, including giving her Abilify. Other common drugs that are potentially lethal to the elderly are Risperdal, Zyprexa, Seroquel, and Geodon.

Why would doctors continue to prescribe these medications? According to The New York Times:

While the Food and Drug Administration has warned doctors that using antipsychotic drugs in elderly patients with dementia increases their risks of death, doctors continue the practice because they have few other good choices, said Dr. Daniel J. Carlat, editor in chief of The Carlat Psychiatry Report, a medical education newsletter for psychiatrists.

“Doctors want to maximize quality of life by treating the patient’s agitation even if that means the patient will die a bit sooner,” Dr. Carlat said.

Until regulators take action based on this report, the families of nursing home residents will have to be extra vigilant about which medications their loved ones are taking. Ask for a full list of all medications, and find out why they were prescribed. If you see any of the antipsychotics on the list, ask to speak with a doctor to see if the medications are necessary, helpful, and not likely to cause harm.

At HensonFuerst Attorneys, we take our role as advocates for nursing home residents very seriously, and we will continue to protect their rights, to speak for people who have no voice. If you believe someone you know has been harmed by harmful medication, please feel free to call us at 1-800-4-LAWMED. Someone is always available—24 hours a day, 365 days a year. You can also learn more on our website at http://www.lawmed.com/.

If you have questions, HensonFuerst has answers.

How does your loved one’s nursing home measure up?  The latest 5-star ratings are now available.

The government’s Centers for Medicare and Medicaid Services have the latest nursing home ratings available on its website… the same ratings soon to be published by U.S. News & World Report magazine.

The Five-Star Quality Rating System was created to help consumers, their families, and caregivers compare nursing homes more easily, and help identify areas about which you may want to ask questions. Nursing home ratings are taken from three sources of data:

• Health Inspections. Onsite visits by a team of trained inspectors who check on the quality of care, inspect medical records, and talk with residents about their care. Inspectors also make sure that the nursing home meets federal quality processes.
• Staffing. This rating looks at the overall number of staff compared to the number of residents…as well as how many of the staff are trained nurses.
• Quality Measures. This measure rates how well a nursing home performs on 10 important aspects of care, such as how well the nursing home prevents and treats skin ulcers, and how well residents are helped in eating and dressing. While this sounds like a valuable measure, the data for Quality Measures are self-reported by the nursing home staff. This makes it the least objective measure, and the most likely to be inappropriately high.

Each of these areas is individually rated, and then these three ratings are combined to calculate an Overall Rating.

To search for and compare nursing homes, click here: Medicare’s Nursing Home Compare. In addition to the 5-star ratings, you’ll also find information about specific areas of deficiencies (if noted) and whether the nursing home is a “Special Focus Facility.”  Special Focus Facilities (SFF) are nursing homes that have a history of persistent poor quality of care. Because of their deficiencies, these nursing homes have been selected for more frequent inspections and monitoring. On Medicare.gov, Special Focus Facilities are marked with this logo:    This is one time when being “special” is NOT a good thing.

For more information about choosing a nursing home, visit our website at http://www.lawmed.com/. And if you suspect that your loved one is being abused or neglected in a nursing home, call us to find out how to keep your loved one safe and discover what your legal options are. Someone is always available at 1-800-4LAW-MED.

The Department of Health and Human Services released a report titled “Questionable Billing by Skilled Nursing Facilities.” The title says it all… but we’re still going to comment.

In recent years, government analyses have discovered improprieties in the amount of Medicare dollars billed by–and paid to–to skilled nursing facilities (a general term that includes nursing homes and other long-term care facilities). We’d like to be clear that Medicare dollars are OUR dollars, yours and mine. Medicare dollars are paid from our tax dollars. So as you read the rest of this blog, keep in mind that this story is personal to everyone in the United States, regardless of whether or not you know anyone in a nursing home.

Here’s a summary of this very long, dry government report:

1. Within two years, from 2006 to 2008, skilled nursing facilities (from here on, I’ll simply refer to this as “facilities”) increased billing for the most expensive therapies by 11%…even though the ages and diagnoses of residents didn’t change. (Translation: Similar resident groups, with higher billing = facilities billed for unused  or unneeded expensive therapies.)
2. For-profit facilities were far more likely than not-for-profit facilities to bill for expensive therapies. AND, the facilities most likely to bill for higher-cost therapies were owned by large chains. (Question: Is this how “for-profits” make more profits?)
3. Some facilities were found to have a pattern of routinely billing Medicare for higher-cost therapies, and/or for having residents stay longer. (Translation: Some facilities routinely abuse the billing system…and now the government knows which ones they are.)

The recommendations to remedy the problems are for Medicare to monitor payments more closely…to change the current method for figuring out how much therapy is needed…to keep a closer eye on those facilities (especially the chains) that seem to have a bigger problem with unusual or “questionable” billing.

For more details without having to read the report itself, Paula Span wrote a really nice opinion piece in The New York Times. In it, Ms. Span says:

Families looking into nursing home care for their elders already have reason to be conscious of the distinctions between for-profit and nonprofit homes. For years, studies have found that nonprofits do better on some vital measurements.

“It’s consistent. The for-profits have the worst staffing ratios and poorer quality based on the number of deficiencies — violations of federal requirements — and the most serious deficiencies,” said Charlene Harrington, professor emeritus of social and behavioral sciences at the University of California, San Francisco, who has led a lot of that research.

In a new study, not yet published, Dr. Harrington also has found that of all forms of ownership, homes owned by the 10 largest chains fared worse than other for-profits. “These facilities are reporting the highest acuity levels” — meaning the most serious conditions for patients — “and the worst staffing,” she told me. “Facilities are supposed to increase their staffs when people are sicker.”

In addition, professor of health polity and management at Texas A&M Catherine Hawes notes that while there are some for-profit facilities that provide good care, in general these facilities have to spend more money making stockholders or owners happy (and possibly wealthy).

“If I had to rely on a single piece of information, deciding about a facility for myself or a loved one, I would choose based on ownership status,” [Dr. Hawes] said.

(Translation: The expert would choose the average not-for-profit facility over a for-profit facility.)

If you have any legal questions about long-term care facilities, check out our dedicated nursing home page: HensonFuerst Nursing Home Abuse and Neglect. If you have questions, HensonFuerst has answers.

There are many different living options for people who are no longer able to live independently, or who require more care than the average family can give. About 70 percent of people over age 65 will require some type of long-term care services during their lifetime. The process of choosing can be overwhelming.

To begin, it’s important to know the differences among various terms. Each type of facility offers different benefits and levels of care, and often must follow different rules and government guidelines in order to maintain its certification and/or funding. The quality of individual facilities varies, as well. Some are wonderful, but many (way too many) are horrific. (On the HensonFuerst website, we provide guidance about how to choose the best-rated care in your area, and we’ll also discuss these topics in detail in future blogs.)

To help ease the confusion, here are some definitions of commonly used terms:

Long-Term Care

“Long-term care” is an overarching term used to describe any service (including many of the services listed below) designed to help people who have chronic illness, disability, dementia, or other condition that requires on-going help. Long-term care services can be provided anywhere, including in the individual’s home or in a residential facility.

Continuing Care Retirement Communities (CCRCs)

CCRCs offer multiple levels of care–Independent Living, Assisted Living, Skilled Nursing Care—housed in different areas of the same community or campus. As the personal and medical needs of residents change, they have the opportunity to move to a different care facility while remaining in the same community—social connections remain in place, friends can stay friends. CCRCs provide residential services (including meals, housekeeping, and laundry), social and recreational services, health care services, personal care, and nursing care.

If you are considering a CCRC, be sure to check the associated nursing home, in person and on the Nursing Home Compare page on www.Medicare.gov. A CCRC contract usually requires you to use the CCRC’s nursing home if you need nursing home care. And some CCRC’s will only admit people into their nursing home if they have previously lived in another section of the retirement community, such as their assisted living or an independent area. CCRCs usually require a large lump-sum entrance fee, and residents must pay a monthly fee. (Licensed as nursing homes/residential care facilities or as homes for the aging.)

Independent Living Community

Independent living communities typically provide meals in a restaurant setting, housekeeping, transportation and various social activities. While there may be wellness programs, care services may or may not be available for an additional charge. These communities are often part of a Continuing Care Retirement Community. (Not licensed.)

Assisted Living Facility

These communities promote independence in a private residence setting, a kind of “home with services” for people who are generally well but still need help with everyday tasks. There is an emphasis on privacy and choice. Residents typically have private locking rooms (unless shared by choice) and private bathrooms. Personal care services are available on a 24-hour-a-day basis. Residents have access to assistance with meals, bathing, dressing and/or medication as needed. In addition, transportation and social activities may be available (not all facilities offer all services, so ask for a list of services in writing). Assisted Living facilities may stand alone, or they may be part of a Continuing Care Retirement Community. There is usually a monthly fee, plus additional fees for added services. (Licensed as residential care facilities or as rest homes.)

Skilled Nursing Facility

Skilled nursing facilities are nursing homes that are certified by Medicare to provide 24-hour nursing care and rehabilitation services, in addition to other services. Many of these communities offer short term, comprehensive rehabilitation programs on an inpatient and outpatient basis. They may be stand-alone facilities, or part of a Continuing Care Retirement Community. (Licensed and regulated by state public health departments.)

Nursing Home

A nursing home is a facility licensed by the state to offer 24-hour skilled nursing care and personal assistance. For people who don’t need to be in a hospital but still require round-the-clock care, a nursing home provides nursing care, personal care, room and board, supervision, medication, therapies and rehabilitation. Rooms are often shared, and communal dining is common. Some nursing homes have special care units for people with Alzheimer’s disease or other serious memory disorders. (Licensed as nursing homes, county homes, or nursing homes/residential care facilities.)

Alzheimer’s/Memory Care

Alzheimer’s or Memory Care communities are a type of service, not particular facility. They provide specialized services to meet the needs of individuals with dementia, brain injury, or Alzheimer’s disease. These services may be provided by an Assisted Living, Skilled Nursing or Residential Community.

Rest Home

These facilities offer 24-hour supervision and supportive services for people who don’t need on-going medical or nursing care. They provide housing, meals, activities, and medication administration.

Hospice Care

Hospice provides care for individuals who are terminally ill, including health services, volunteer support, grief counseling, and pain management. Although most hospice programs are only allowed to offer services to people who are thought to have less than six months to live, some hospitals are providing hospice to people with a documented terminal illness who need palliative care. These services can be provided in a person’s home, a hospital, or a long-term care facility.

Adult Day Care

Even though the name sounds a bit condescending, Adult Day Care can be very helpful for adults who are functionally impaired, but who want or need an alternative to live-in care. These programs run during the day (much like child day care), and provide variety of health and wellness, social, and related support services in a safe, protective setting.

For More Information…click the links below:

HensonFuerst Attorneys Nursing Home Abuse webpage

National Clearinghouse for Long-Term Care Information

Medicare.gov

Many people who wind up in a nursing home are transferred there after a hospital stay. But an article in today’s The Washington Post points out a technicality that could block your ability to have Medicare cover the cost of  your nursing home stay.

Basically, everyone in the hospital is categorized as being in either “for observation” or as a regular “inpatient.” Here’s the tricky part:

Even if you are admitted as an inpatient, the hospital can switch you to observation status; in that case, the hospital is required to notify you.

If you do not have three consecutive days of hospitalization as an inpatient — excluding the day of discharge — Medicare will not cover a subsequent stay in a nursing home. For those who do qualify, Medicare pays for up to 100 days of rehabilitation or skilled nursing care.    [from The Washington Post article, emphasis added]

Although you can’t force the hospital to change your status from “observation” to “inpatient,” you can ask what your status is, and why. You can also talk with your personal physician, who can request (but not force) a status change.

If you are admitted to a nursing home without the required three days as an inpatient, there are still steps you can take to try to get Medicare to cover your costs.

1. When you enter the nursing home, ask to have them bill Medicare for your care.  If Medicare denies the claim, you can appeal the decision.
2. If the nursing home won’t bill Medicare, then you can complete a form called a “Notice of Exclusions from Medicare Benefits: Skilled Nursing Facility” (click the form name for an online copy of the form). The nursing home won’t bill you while you wait for a response from the government (and you know how long it can take to hear from a government agency).

If Medicare does not pay for your costs, you will be responsible, so know your rights…and continue to appeal any denial until you have no more options. If you need help, contact a local Estate/Medicare lawyer, who can usually provide technical assistance in these types of matters.

Sources of Information

The Washington Post

www.medicare.gov

HensonFuerst attorneys (www.lawmed.com)

According to an article on WRAL.com, the North Carolina Department of Health and Human Services (DHHS) has recommended that the Centers for Medicare and Medicaid Services fine Britthaven of Chapel Hill nursing home for violations that led to the hospitalization of six patients in February. One patient, 84-year-old Rachel Holliday, died.

Ms. Holliday and eight other patients tested positive for opiates, powerful and controlled pain medications–and many of them had not been prescribed opiates at all.

Angela Almore, 44, of 724 Berwick Valley Lane in Cary, was indicted in June on one count of second-degree murder and six counts of felony patient abuse. Almore worked as a registered nurse at Britthaven. Prosecutors allege that Almore drugged the patients to make them more manageable. [from WRAL.com]

After an extensive investigation, the DHHS Nursing Home Licensure Section found that Britthaven of Chapel Hill “didn’t ensure patients were protected from abuse, its services didn’t meet professional standards, unnecessary drugs were prescribed and significant medication errors occurred.”

The requested fines were $2,500.00 for each violation, for a total of $20,000.00.

HensonFuerst’s Nursing Home Abuse team continues to conduct an independent investigation into these and other episodes of nursing home abuse and neglect. If you have questions about potential abuse, we’re here to provide answers. Call us anytime, day or night, at 1-800-4LAW-MED.

In North Carolina, if a restaurant scores below a “C” grade for sanitary reasons during a health inspection, the business must close until it passes inspection.  If property owners allow their homes to fall into disrepair, the state can condemn the residence as unsafe, and in some cases, the building may be demolished.

But if a nursing home “fails” Medicare inspections…or if the facility has a history of unsafe practices, or of hiring workers who bring harm to the feeble and elderly residents, do you know what happens?

There’s a small fine. But that’s more than offset by the money Medicare will continue to pay into the nursing home on behalf of the patients living there.

Case in point: Britthaven of Chapel Hill.  This nursing home also has been rated by Medicare as one of the worst in the country. Britthaven of Chapel Hill has been called out as a “Special Focus Facility,” which means that they have a history of persistent poor quality of care. In February, six Britthaven patients were hospitalized from morphine overdose…one patient died of complications. A nurse has been charged with murder in that case.

And now, this article in Saturday’s News & Observer, and this article in today’s newspaper.

If you have legal questions about nursing home care, feel free to contact the attorneys of HensonFuerst. If you have questions, we have answers.