Health Care

Monday, April 05, 2010

Impacts of Staying Older Longer

It’s common knowledge that people these days are living longer than ever, with life expectancy approaching 80 years of age (especially for women), and over-85-year-olds being the fastest growing segment of our population for some time now. Now a new study by the prestigious MacArthur Foundation says that we ain’t seen nothing yet — that the mid-21st century is going to see men and women routinely living into their late 80s and early 90s, respectively, and 100-year-olds numbering nearly 2 million!

Richard Peck of SANAPSeniors.com gives his opinion of the impacts of this longevity revolution at:

http://www.snapforseniors.com/Blogs/tabid/417/EntryId/25/Staying-Older-Longer.aspx

Saturday, March 27, 2010

Health Care Reform Provisions Affecting Older Adults

The National Academy of Elder Law Attorneys provided a very good overview of the new health care law and some of its most pertinent provisions are outlined below.

On March 23, 2010, President Obama signed a comprehensive health care reform bill (H.R. 3590) into law.  On March 25, Congress passed the Reconciliation Act of 2010 (H.R. 4872) which modifies H.R. 3590.  Taken together, these two bills comprise the health care reform package.  Important provisions for older adults:

Medicare

• Provides a $250 rebate to Medicare beneficiaries who reach the Part D coverage gap in 2010 (Effective January 1, 2010).
• Gradually eliminates the Medicare Part D doughnut holeby 2020:
• For brand-name drugs, requires pharmaceutical manufacturers to provide a 50% discount on prescriptions filled in the Medicare Part D coverage gap beginning in 2011, in addition to federal subsidies of 25% of the brand-name drug cost by 2020 (phased in beginning in 2013)
• For generic drugs, provides federal subsidies of 75% of the generic drug cost by 2020 for prescriptions filled in the Medicare Part D coverage gap (phased in beginning in 2011)
• Provides Medicare coverage, with no co-payment or deductible, of an annual wellness visit and creation of a personalized prevention assessment and plan. Prevention services include referrals to education and preventive counseling or community-based interventions to address risk factors.
• Eliminates Part D cost-sharing for full-benefit dual eligible beneficiaries receiving home- and community-based services.
• Restructure payments to Medicare Advantage (MA) plansby setting payments to different percentages of Medicare fee-for-service (FFS) rates, with higher payments for areas with low FFS rates and lower payments (95% of FFS) for areas with high FFS rates. Phase-in revised payments over 3 years beginning in 2011, for plans in most areas.
• Require the Secretary to suspend MA plan enrollment for 3 years if the medical loss ratio is less than 85% for 2 consecutive years and to terminate the plan contract if the medical loss ratio is less than 85% for 5 consecutive years. (Effective beginning in 2011.)
• Although the provisions cut MA payments as a whole, there are no provisions for cuts to mandated benefits. As a result of the payment reductions, MA plans may cut extra, optional benefits such as vision and dental. The provisions for equalizing payments between MA plans and traditional Medicare are based on a recommendation by the non-partisan Medicare Payment Advisory Commission (MedPAC), and supported by advocates for Medicare beneficiaries such as the Center for Medicare Advocacy.
• These and other provisions strengthen Medicare and extend by nine years the life of the Medicare Trust Fund which was projected to be depleted in 2017. 
• Applies the Medicare tax to net investment income for individuals making $200,000 and over and couples making $250,000 and over.

On the negative side, H.R. 3590:

• Establishes an Independent Payment Advisory Board (IPAB), which will have authority to make recommendations for Medicare cost-savings. The recommendations will take effect if Congress does not enact an alternative proposal that achieves the same cost savings. The board cannot make any recommendations that will impact premiums or benefits. Also, the board cannot make any recommendations for cuts in a year when national health expenditures grow at a higher rate than Medicare costs. The board is required to make recommendations with beneficiary access in mind. A Government Accountability Office study on beneficiary access is required in 2014. Congress is required to reexamine the board in 2017 and will have the option to terminate it. The IPAB is required to produce a public report on system-wide (not just Medicare) health care costs, patient access to care, utilization, and quality of care. It also is required to submit to Congress and the President recommendations to slow the growth of national health expenditures, while preserving or enhancing quality of care.
• TiesMedicare Part D premiums to income, and will move more Part B and Part D beneficiaries into higher-income categories — meaning higher premiums —due to a freeze on thresholds.

Insurance Reforms

• Effective six months after enactment, insurance companies can no longer deny children coverage based on a preexisting condition.
• Starting in 2014, insurance companies cannot deny coverage to anyone with preexisting conditions.
• Provides immediate assistance to individuals with pre-existing conditions through establishment of high-risk pools.
• Ensures that minimum covered benefits include products and services that enable people with disabilities to maintain and improve function, such as rehabilitation and habilitation services and devices and mental health services.
• Effective six months after enactment, requires insurers to offer and renew coverage for any applicant (guaranteed issue and renewal).
• Effective six months after enactment, require individual and group plans to extend dependent coverage to adult children up to age 26, prohibit rescissions of coverage, and eliminate waiting periods for coverage of greater than 90 days.
• Require group plans to eliminate lifetime limits on coverage and beginning in 2014, eliminate annual limits on coverage.

Medicaid

• Expands Medicaid to cover individuals 64 and under with incomes up to 133 percent of the federal poverty line.
• Increases federal Medicaid matching to all states (except expansion states) as follows: 100% in 2014, 2015, and 2016; 95% in 2017, 94% in 2018; 93% in 2019 and 90% thereafter to finance coverage for newly eligible individuals.  
• Increases theMedicaid drug rebate percentage for brand name drugs to 23.1 percent (except the rebate for clotting factors and drugs approved exclusively for pediatric use, which increases to 17.1 percent); increase the Medicaid rebate for non-innovator, multiple source drugs to 13 percent of average manufacturer price; and extend the drug rebate to Medicaid managed care plans.
• Modifiesthespousal impoverishment statute to mandate that states include the spousal impoverishment protections in their waiver programs, and that the spouses of all HCBS waiver participants, including those who qualify as medically needy, have the protections available. The provision will sunset after five years.
• Extendsthe Medicaid Money Follows the Person (MFP) Rebalancing Demonstration program through September 2016. The MFP program was authorized in the Deficit Reduction Act of 2005 to encourage states to transition Medicaid enrolled individuals from nursing homes to the communities. The Medicaid coverage follows the person to the community and pays for the home and community-based services required.

Community First Choice Option

• Establishesthe Community First Choice Option, a state plan option under section 1915 of the Social Security Act to provide community-based attendant supports and services to individuals with disabilities who are Medicaid eligible and who require an institutional level of care. These services and supports include assistance to individuals with disabilities in accomplishing activities of daily living and health related tasks. States that choose the Community First Choice Option will be eligible for an enhanced federal match rate of an additional six percentage points for reimbursable expenses in the program.  This provision sunsets 5 years after it starts on October 1, 2011.
• The Community First Choice Option also will require data collection to help determine how states currently are providing home- and community-based services, the cost of those services, and whether states currently offer individuals with disabilities, who otherwise qualify for institutional care under Medicaid, the choice to receive home- and community-based services instead, as required by the U.S. Supreme Court in Olmstead v. L.C. (1999).
• The Community First Choice Option also will modify the Money Follows the Person Rebalancing Demonstration to reduce the amount of time required for individuals to qualify for that program to 90 days.

Long-Term Care

• Establishes the Community Living Assistance Services and Supports (CLASS) program, a new national long-term care insurance program funded through voluntary payroll deductions, which will provide a cash benefit to individuals who are unable to perform ADLs for the purchase of community living assistance services and supports. According to the Congressional Budget Office, the CLASS program will reduce the deficit by $70 billion over 10 years due to the payment of premiums by enrollees (the voluntary payroll deductions) in excess of benefits paid out in the first decade, and including federal Medicaid savings.
• Creates the State Balancing Incentive Program (10/1/2011 – 9/30/2015) to provide enhanced federal Medicaid matching to states which currently spend less than 50 percent of total expenditures for long-term care on services in the home or community to increase their proportion of non-institutionally-based long-term care services.

Care Coordination

• Creates theIndependence at Home demonstration program to provide high-need Medicare beneficiaries with primary care services in their homes and allow participating teams of health professionals to share in any savings if they reduce preventable hospitalizations, prevent hospital readmissions, improve health outcomes, improve the efficiency of care, reduce the cost of health care services, and achieve patient satisfaction.
• CreatesanInnovation Center at the Centers for Medicare and Medicaid Services to test, evaluate, and expand different Medicare and Medicaid payment structures to foster patient-centered care and care coordination across treatment settings and slow cost growth.
• Requires the Secretary of Health and Human Services to improve coordination of care for dual-eligibles through a new office or program within the Centers for Medicare and Medicaid Services.
• Establishesa Medicare Shared Savings Program that promotes accountability for a patient population and coordinates services under Medicare parts A and B, and will encourage investment in infrastructure and redesigned care processes for high quality and efficient service delivery. It will allow groups of providers who voluntarily meet certain criteria to work together to manage and coordinate care for Medicare fee-for-service beneficiaries through Accountable Care Organizations (ACOs) under Medicare. ACOs that meet quality performance standards are eligible to receive payments for shared savings if costs are a certain percentage below a benchmark.
• Establishesanational Medicare pilot program to develop and evaluate paying abundled payment for an episode of care that begins three days prior to a hospitalization and lasts until 30 days following discharge.
• Establishes aMedicaid demonstration project beginning January 1, 2012, and ending December 31, 2016 to evaluateintegrated care around a hospitalization.
• Creates anew Medicaid state plan option under whichMedicaid enrollees with chronic conditions (including a mental health condition, substance use disorder, asthma, diabetes, heart disease, or weight problem) can designate a provider, team of health care professionals, or a health team as theirhealth home.
• Establish a program to provide grants to or enter into contracts with eligible entities to establishcommunity-based interdisciplinary, interprofessional teams to support primary care practices. 

End-of-Life

• No end-of-life provisions are included in H.R. 3590.

Nursing Home Transparency

• Requires nursing homes to disclose their owners, operators, suppliers, financers, and others with whom they do business so they can be held accountable for the care their residents receive.
• Requires nursing homes to take steps internally to reduce criminal and civil violations;
• Establishes a Quality Assurance and Performance Improvement Program to improve quality assurance standards.
• Requires the government to implement a system to collect and report information about how well nursing homes are staffed, including accurate information about the hours of nursing care residents receive; staff turnover rates; and how much facilities spend on wages and benefits.
• Requires cost reports that nursing homes will file with the government to show expenditures by category — nursing, therapy, capital assets, and administrative services.
• Requires civil monetary penalties (fines) to be held in escrow pending appeals rather than allowing nursing homes to delay payment indefinitely while they file appeals.
• Implements a pilot program to improve federal government oversight of nursing home chains that have quality of care problems.
• Provides training to workers who care for residents with dementia and to prevent abuse.

Elder Justice

H.R. 3590 contains the Elder Justice Act (EJA), which:

• Establishes an Elder Justice Coordinating Council to make recommendations to the Secretary of Health and Human Services on the coordination of activities of federal, state, local and private agencies and entities relating to elder abuse, neglect, and exploitation. Recommendations are due in two years.
• Provides $400 million in first time dedicated funding for Adult Protective Services (APS).
• Provides $100 million for state demonstration grants to test a variety of methods to detect and prevent elder abuse.
• Provides $26 million for the establishment and support of Elder Abuse, Neglect and Exploitation Forensic Centers to develop forensic expertise and provide services relating to elder abuse, neglect, and exploitation.
• Provides $ 32.5 million in grants to support the Long-Term Care Ombudsman Program and an additional $40 million in training programs for national organizations and state long-term care ombudsman programs.
• Authorizes $67.5 million in grants to enhance long-term care staffing through training and recruitment and incentives for individuals seeking or maintaining employment in long-term care, either in a facility or a community based long-term care entity.

Criminal Background Checks

• Extends to all states an existing pilot program that enables states to conduct national criminal background checks, including fingerprint checks, on individuals who apply for direct patient access jobs in long-term care facilities and with home care agencies that receive funding from Medicare or Medicaid, thus eliminating the ability of persons with criminal histories to move from state to state to work with vulnerable seniors and persons with disabilities. 
• The federal government will provide federal matching funds to states to conduct these activities. The provision specifies that the checks should be implemented in such a way that does not result in application fees for long-term care workers.
• States will be required to guarantee (directly or through donations from public or private entities) a designated amount of non-federal contributions to the program. The federal government will provide a match equal to three times the amount a state guarantees; except that federal funds will not exceed $3 million for newly participating states and $1.5 million for previously participating states.

Workforce

• Authorizes $10.8 million to Geriatric Education Centers (GECs) to support training in geriatrics, chronic care management, and long-term care for faculty in a broad array of health professions schools, and direct care workers and family caregivers; GECs also will develop curricula and best practices in geriatrics.
• Expands the Geriatric Academic Career Awards to advanced practice nurses, clinical social workers, pharmacists, and psychologists, and create a parallel Geriatrics Career Incentive Award program for Master’s level candidates ($10 million over 3 years).
• Establishes federal traineeships for individuals who are preparing for advanced education degrees in geriatric nursing, long-term care, and gero-psychiatric nursing.
• Provides grants to foster greater interest among health professionals (advanced practice nurses, clinical social workers, pharmacists, and students of psychology) to enter the field of geriatrics, long-term care, and chronic care management.
• Requires federally funded GECs to offer one of two required activities (in addition to health professions training), one being to provide at least two courses each year, at no charge or nominal cost and in collaboration with appropriate community partners, to family caregivers who support frail older adults and individuals with disabilities.
• Authorizes $10 million over three years to establish advanced training opportunities — such as tuition support for obtaining a nursing degree or specialized training — for direct care workers (certified nurse aides, home health aides and personal/home care aides) who already are employed in long-term care facilities.
• Provides $5 million per year, for three years, to conduct a Medicaid demonstration in up to six states for development of training programs for personal and home care aides.
• Establishes a national panel of long-term care workforce experts to develop the core competencies for these training programs and to make recommendations on how such training could be provided. This requires the Secretary of Health and Human Services to conduct an evaluation of the demonstration and report recommendations to Congress. 

Monday, March 22, 2010

Health Reform Passes House of Respresentatives - Now What?

When the House approved the historic $940 billion health care reform bill yesterday, it was voting on a bill passed by the Senate in December. That bill contained a number of provisions affecting the elderly and disabled, including several that will significantly improve the Medicaid options available for individuals with chronic needs.

But before a final bill can be sent to President Obama, the Senate must sign off on a 153-page package of House-approved amendments to the legislation. Approval of these "reconciliation" changes will require only a simple majority of the Senate, however.

Monday, March 22, 2010

Health Care reform Passes House - Does it do Anything for Long Term Care?

The House Health Care Reform bill that passed the House last Sunday (3/21/10), included the Community Living Assistance Services and Supports (CLASS) Act, which will establish a new national long-term care insurance program. CLASS continues to survive the long legislative march towards health reform and, given the CLASS Act's short-term contribution to revenue, the betting on Capitol Hill is that the Act will be in any health reform bill that makes it to President Obama's desk.

Under the voluntary CLASS program, Americans will pay a premium, originally estimated at $65 per month. After they had contributed for at least five years, participants who needed long-term care would be eligible for a modest benefit to pay for a range of services that would help them stay in their homes. In the House bill, that benefit would depend on the degree of incapacity, but would average $50 a day.

Although versions of the CLASS Act are in the House bill and in the Senate Health, Education, Labor and Pensions (HELP) committee's health care reform bill, it is unclear whether the Act will be part of the final Senate bill, which will be a melding of the HELP and Finance committees' health reform measures. But the CLASS Act has one huge advantage that could ensure its survival: it helps the bottom line of any final legislation by being a revenue generator for about two decades. Id CLASS does end up passing the Senate and House unchaged it would take effect in late 2012 or early 2013.

Stay tuned for further developments.

Monday, March 22, 2010

Health Care Reform passes the House - What Does it Do for Medicaid?

The good news about the Senate bill is that it provides many state incentives to provide care to individuals in their homes rather than making them go to a nursing home for help.

The bill's Medicaid provisions include: a new program that will provide states more money to cover home and community-based services (HCBS); a new Community First Choice Option for individuals otherwise eligible for Medicaid institutional coverage; an enhanced HCBS state plan benefit authorized by the Deficit Reduction Act of 2005; spousal impoverishment protections for spouses of all individuals receiving HCBS waiver and certain state plan services; authorization of the Money Follows the Person program through 2016; and additional funding for Aging and Disability Resource Centers.

The National Senuior Citizens Law Center provided an an analysis of these provisions and I am outlining some of the key provisions below.

The Senate’s approach will be a welcome change if passed since its proposals would further weaken Medicaid’s institutional bias by providing more, and better, opportunities for prospective Medicaid enrollees to avoid unnecessary institutionalization.

Community-Based Attendant Service Option

The Alabama Medicaid agency generally develops a clinical eligibility standard for Medicaid coverage. Individuals who meet this standard and also meet Medicaid’s financial eligibility requirements are guaranteed coverage for nursing facility services. In Alabama there is really no other option for the person who does not want to bew insitutionalized.

Section 2401 of the Senate bill, entitled "Community First Choice Option," would make a new service available to the Medicaid population and would offer states the incentive to provide coverage for it. The provision provides states the option to offer community-based attendant services as a state plan benefit to individuals who meet the state’s nursing facility clinical eligibility standard. The provision would not only free states from the expenditure caps currently applicable in HCBS waiver programs, but it also dictates that states receive an increase in their standard Medicaid reimbursement rate of six percentage points for the services provided through the option.

Money Follows the Person (Section 2403)

The Deficit Reduction Act of 2005 (DRA) authorized $1.7 billion for the Money Follows the Person program (MFP), under which 31 states (not Alabama) were awarded grants to transition Medicaid-enrolled nursing facility residents to their homes or other community settings. The "grants" states have received come in the form of an enhanced federal match for the services provided to program participants for the first 12 months after a participant’s transition. Approximately 37,000 individuals were projected to be transitioned under MFP. The DRA authorized MFP through 2011.

Section 2403 of the Senate bill, entitled "Money Follows the Person Rebalancing Demonstration," authorizes continued federal support for MFP through 2016, and also relaxes one of the program’s primary eligibility requirements. The DRA mandated that program participation be available only to Medicaid-enrolled nursing facility residents who have been institutionalized for not less than six months. The law also authorized states to impose a longer minimum residency of between six months and two years. The Senate bill reduces the minimum residency requirement from six months to 90 days and eliminates the state authority to impose a longer minimum period. However, any days an individual spends in an institution receiving short-term rehabilitative services will "not be taken into account for purposes of determining the 90-day period" under the proposal.

Temporary Expansion of Spousal Impoverishment Protections (Section 2404)

Section 2404 of the Senate bill, "Protection for Recipients of Home and Community-Based Services Against Spousal Impoverishment," would modify the spousal impoverishment statute to mandate that states include the spousal impoverishment protections in their waiver programs, and that the spouses of all HCBS waiver participants.