Sunday, December 20, 2009

China's Coming Crisis Of Elder Care

Global Times

As China's one-child policy moves to its next generation, the "4-2-1" problem, namely four grandparents and two parents with only one adult child to look after them, has become a pressing concern for many families.

The one-child policy has severely challenged China's traditional family system. As the old Chinese saying goes, "Raise sons to provide for old age." Under the old system, the younger generation, men in particular, served as the main providers for older family members. This is the logic behind the traditional thinking of having more children, especially boys.

But the one-child policy leaves many families with little choice. Therefore, regardless of gender, the only child faces the challenge of providing for all the aged in the family when time comes. It is like an inverted pyramid – the pointed side has to support all the weight of the whole structure.

However, for many young people in the urban areas, who were born as the only child in the late 1970s or later, the time hasn't come yet. Most of their parents are either working or have social securities and personal savings to support themselves.

Their grandparents are not their problems, since their parents basically take care of the issue by sharing the responsibilities with their brothers and/or sisters and using their own resources.

China hasn't moved to the stage of "4-2-1" yet. The parents of China's first generation of one child are still the main providers now.

Mostly in their late 50s or early 60s, these people are quickly draining their lifetime savings to help their children by buying them apartments, careers, or other things. They stretch themselves to simultaneously care for their children as well as their parents.

But the situation won't last long. With China's living expenses shooting up and the increasing life span of old people, responsibility is going to shift.

Unlike Western countries, which have a developed social support system for the elderly, China is still experimenting with and reforming its public welfare system.

Not everyone in China has social insurance, especially among the rural population. When these social mechanisms fail, the last resort is their only child.

Some young people are acknowledging the challenge ahead of them. It is a daunting task even to imagine how a young couple could support four aged people or more while trying to make ends meet for their own small family.

Many of them can only cross their fingers that their parents won't have any serious illnesses that go beyond the coverage of social insurance or their own personal savings.

Even when the financial needs are not a big concern, how to take care of the other personal and emotional needs of the older generation is going to be a tricky task for these only children.

I am lucky enough to have two siblings, and even then it's hard sometimes to make sure somebody gets home for the Spring Festival with our parents. I can't imagine how bad the situation might be for those one-child families, especially given how scattered across the country many families are.

The living situation is another problem. When parents have aged to the stage where they can't take care of themselves, where to put them becomes a real headache. One can either live with the parents or send them to an old folks home.

But the latter doesn't sound like a good solution as putting parents in a nursing home is totally against Chinese beliefs.

China's elder care industry is also still in the early stage of development, as the Global Times reported yesterday.

My mother joked once that she could go there, but I could tell from her eyes that she didn't mean it.

However, with both sets of parents needing help, young families may face a very awkward situation. It is already very difficult for grown-ups to live with their parents. Living with in-laws could be even worse.

But the worst scenario is to put both sides of the parents under the same roof with the young couple, especially if there is a young grandchild around.

We can only hope that time and reform will solve everything. When the "4-2-1" crunch comes, we must already have a terrific social support system for the aged, no matter where they live or how many children they have.

Saturday, December 19, 2009

Human Services Chief: Cuts Hurt Elder Care


Fitchburg, MA -- People receiving services and others who provide them testified at a forum at Fitchburg State College last night on how cuts to state aid have affected programs.

The forum, moderated by Secretary of Health and Human Services Dr. JudyAnn Bigby, was one of 19 planned across the state seeking input on the upcoming state budget and how to fill a projected $3 billion deficit in fiscal 2011. A panel comprised of Health and Human Services officials also attended.

In a pre-recorded address played at the start of the forum, Gov. Deval Patrick said his administration was going through the budget line by line to find savings while still providing services to the most vulnerable populations in the state. He said his administration was building a budget around community values.

Greg A. Giuliano, incoming executive director of Montachusett Home Care — an agency that provides in-home and community-based services to the elderly — said cuts in state funding have diminished the agency’s ability to provide services.

“It’s important to back up the rhetoric about building a budget around community values,” he said.

He said the agency’s parent organization, Mass. Home Care, which works to keep elders from having to enter nursing homes, has more than 2,000 elderly on a waiting list for services.

The state, he said, impounded $2.5 million that was targeted for staff who go into hospitals and educate people on their rights to community care that can divert them from nursing homes. Additionally, he said, the group-home model that places four elderly people in a ranch house instead of a nursing home has been derailed by the state for two years; and the elder abuse program was cut by $1 million.

He urged the state to restore funding to those areas and not make further cuts.

Suggestions from the audience to fill the state’s deficit to avoid further cuts to services included legalizing marijuana and taxing it to increase revenues, increasing taxes on tobacco products and just generally increasing taxes.

Linda C. Lolly, a personal care assistant for people with mental illnesses, was a proponent of legalizing and taxing marijuana to save in-home services to those she supports.

“I have seen it over and over again that an elderly person can stay in their home when someone comes in and gives them a bath and gets them dressed for the day,” Ms. Lolly, who works for Arcadia Health Care in Worcester, said. “That’s just a few hours instead of having them go into nursing homes that cost thousands of dollars because there is no one else to do it for them.”

Dr. Bigby said the upcoming budget cycle is going to be even more difficult than last year because fiscal 2010 was balanced on $2.1 billion from one-time revenues. Moreover, there is only $561 million left in the state’s stabilization fund, she said, that may be needed in this budget cycle.

The Health and Human Services budget totals $13.7 billion — 51 percent of the state’s overall budget of $27 billion.

Friday, December 18, 2009

26 Arrests In Medicare Fraud Case

Associated Press

FORT LAUDERDALE, Fla. — Federal agents arrested 26 suspects in three states Tuesday, including a doctor and nurses, in a major crackdown on Medicare fraud totaling $61 million in separate scams.

Arrests in Miami, Brooklyn and Detroit included a Florida doctor accused of running a $40 million home health care scheme that falsely listed patients as blind diabetics so that he could bill for twice-daily nurse visits.

The U.S. Department of Justice and U.S. Department of Health and Human Services said the indicted suspects lined up bogus patients and otherwise billed Medicare for unnecessary medical equipment, physical therapy and HIV infusions.

Indictments were issued for 32 people in all, but the status of the other suspects wasn't immediately known.

Miami Dr. Fred Dweck, along with 14 people with whom he worked, was accused in an indictment of running a scam to tap a Medicare program that pays very high rates to care for the sickest patients.

Dweck referred about 1,279 Medicare beneficiaries for expensive and unnecessary home health and therapy services, bribing the owners of two Miami clinics to join the scam. He also faked medical certifications, according to the indictment.

A telephone listing for Dweck could not be found and it was unclear if he had a lawyer.

"No matter what type of fraud is committed, there is one common denominator and that denominator is greed," Assistant Attorney General Lanny Breuer said. "Medicare fraud is not a victimless crime. It hurts every American taxpayer by raising the cost of health care."

The raids come a week after a report that Miami-Dade County received more than half a billion dollars from Medicare in home health care payments intended for the sickest patients in 2008, which is more than the rest of the country combined, according to a report by the Department of Health and Human Services' Office of Inspector General. Medicare paid the county about $520 million, even though only 2 percent of those patients receiving home health care live here.

In Detroit's raids, suspects paid recruiters to find patients willing to feign symptoms to justify expensive testing, including nerve conduction studies, federal authorities said.

A mother and son were charged in Brooklyn with billing Medicare $246 per patient for expensive shoe inserts reserved for diabetes patients, even though they only provided cheap, over-the-counter versions.

Including Tuesday's arrests, a Medicare Fraud strike force formed by the Justice and Health departments has now charged suspects accused of bilking Medicare of more than $1 billion in less than two years.

The pilot strike force, which started in Miami in 2007, has indicted more than 460 suspects in Medicare fraud scams. The program is now in Los Angeles, Houston and Detroit. HHS Secretary Kathleen Sebelius also announced Tuesday the operation will expand to Tampa, Fla., Baton Rouge, La., and Brooklyn.

Cleaning up an estimated $60 billion a year in Medicare fraud will be key to President Barack Obama's proposed health care overhaul. HHS and DOJ have promised more money and manpower to fight the fraud.

Wednesday, December 16, 2009

The New Old Age - Who We Are Now

NY Times

We’re still, in most cases, female.

We’re still likely to be employed, usually full time.

We spend an average of 19 hours a week at this second job, caring for our older relatives.

Every few years, the National Alliance for Caregiving and AARP team up to survey the nation’s family caregivers and produce a massive, highly detailed study funded by Metlife. The first of these reports appeared in 1997, the next in 2004. The latest, released this week, provides an interesting picture of what’s changed in five years and what hasn’t.

The overall report, “Caregiving in the U.S. 2009” [pdf], includes people taking care of family members of any age, including children with special needs. But the researchers, helpfully, have also published a companion study of people caring for adults over 50.

It shows that elder care remains primarily women’s work and that most caregivers continue to juggle unpaid caregiving and paid work.

What’s changed? The people we take care of are older. In 2004, the proportion of elders over age 75 was 55 percent; now it’s 63 percent. We’re older, too: caregivers’ average age rose from 48 to 50. Unsurprisingly, then, a higher proportion are caring for seniors with Alzheimer’s disease and other forms of dementia.

But we have less paid help. The proportion whose older relatives had aides, housekeepers or other paid workers dropped to 41 percent from 46 percent; the use of paid help also declined among all caregivers. The data don’t specify why families use less paid caregiving, but AARP’s Elinor Ginzler pointed to the most plausible explanation.

“Likely, this is related to the economy,” Ms. Ginzler said this week. “They can’t afford it.”

Perhaps in response, unpaid caregiving supplied by other family and friends has risen.

I’m always a little relieved, since we all hear too many heartbreaking stories of families crushed by their responsibilities, to be reminded by this and other caregiving studies that a majority of families handle the burden without great hardship or crippling trauma. Most respondents in this study said caregiving hasn’t harmed their own health or created much physical strain, and only a third found caregiving highly stressful emotionally. (To which I can hear a chorus of readers replying, “Just wait.”)

What kind of support would families caring for their elders most like to see? Topping the list is a $3,000 tax credit, followed by respite services, a voucher program that would pay family members minimum wages to be caregivers, and transportation services.

Tuesday, December 15, 2009

Seniors Teach Med Students Finer Points Of Elder Care

UAB Reporter

Lorain Devito is an expert on the elderly. She knows their tendencies, their likes and their dislikes. She knows how strong their will can be. She also knows their fears.

Devito knows these things because she, too, is elderly. Devito is a resident at Episcopal Place, a Section 202 supportive-housing program that provides seniors and disabled adults with restricted income safe and affordable housing and access to related services in a home-like environment.

She’s a very busy lady. Devito, a diabetic, swims regularly and helps interview potential Episcopal Place residents. She also volunteers for two programs in the School of Medicine — the Senior Mentor Program and the History of Medicine Program — and she meets with medical students to discuss health care.

“I look at this as an opportunity to give back and an opportunity to help the physicians of tomorrow better understand geriatrics,” Devito says.

Both programs have been a part of the School of Medicine and the Division of Gerontology, Geriatrics and Palliative Care for several years and recently received a jolt with a $2 million grant from the Donald W. Reynolds Foundation and a $1 million match from the university. Christine Ritchie, M.D., director of palliative and supportive care, is the principal investigator for the four-year grant, which will improve education for the school’s 875 medical students and for 350 residents, numerous faculty and community physicians.

“Both programs were part of the original grant proposal and are receiving much-needed funding,” says Angela Rothrock, Ph.D., assistant professor in gerontology, geriatrics and palliative care and associate director for the day-to-day operations of the UAB Reynolds Program. “The grant will enable us to change the programs — particularly the Senior Mentor Program — in positive ways. It’s certainly reinvigorated the programs and helped us increase the diversity of our seniors.”

Stan Massie, M.D., associate professor of general internal medicine, oversees the Senior Mentor Program for first-year medical students. Richard Sims, M.D., professor of geriatrics, is the co-director.

Rothrock says Massie and Sims were responsible for starting the program and have kept it going with little funding.

The course is a unique opportunity for first- and second-year medical students to be paired with a senior citizen living in the Greater Birmingham area.

Among the goals of the program:
• Provide students with an opportunity to develop a working relationship with a patient
• Expose students to community-dwelling elders
• Enable students to visit elders outside of UAB
• Provide opportunities for students to practice their interviewing skills
• Make students aware of some of the principles and challenges involved in care of the elderly

Two students are paired with an adult and visit their senior mentors approximately six to seven times in two years.

“There are specific things we want them to learn each visit,” Rothrock says. “One visit might be learning to do history-taking. One might be learning to do a cognitive assessment, a depression scale or a medication review. There are specific clinical skills we want them to learn. But we also want them to learn that all older adults are not sick and frail. There are older, healthy and vibrant adults in our community who they have a lot to learn from.”

Focus on geriatrics

The Donald Reynolds Foundation grant is part of $80 million it gave to UAB and 39 other medical schools to focus student learning on better care for the elderly.

The grant requires internal medicine residents to spend one month in geriatrics training in settings that include acute care for the elderly, a long-term care facility, outpatient clinics and home-care visits. Other programs, including interactive, online training modules and special geriatric training for residents in internal, emergency, family and pediatric medicine, also are in development.

The Senior Mentor Program also will evolve into an interdisciplinary program.

“It won’t just be a medical student working with an older adult, it will also be a nurse, a social worker, a dental and a therapy-based-practice student working in teams,” Rothrock says. “The professionals in training will discuss how to work in an interdisciplinary team to best care for older adults.”

Training in geriatrics, the area of medicine that focuses on diagnosing and treating diseases and problems particular to older adults, is essential for future physicians.

The first Baby Boomers begin turning 65 in 2011, which creates an additional sense of urgency. The Silver Tsunami, or wave of seniors seeking medical care, is expected to increase dramatically during the next decade.

“Given the changing demographics, we’d have to train far more physicians than we are able in order to have enough geriatricians,” Rothrock says. “So even if you’re not a geriatric specialist, you’re going to have to care for older adults. What we can create are geriatric-friendly physicians so that any physician coming out of training is attuned to geriatric needs and able to recognize that caring for older adults requires a different perspective on health care.

“If we don’t train health-care professionals in general to care for older adults, from basic communication skills to very technical clinical skills, they’re not likely to learn it,” Rothrock says. “In the average medical journal you’re learning about outcomes in a 40-year-old white man, and that’s not who’s going to be coming into their clinics.”

Mentors are the teacher

That’s why the mentorship program is so valuable to students. They get an opportunity to begin learning the way seniors live and think.

In fact, Rothrock makes it known when she is recruiting the seniors that they are to make sure they do one specific thing with the students — speak their mind.

“I tell these local residents, ‘You’re the teacher. If you don’t like the way they ask you questions, tell them,” Rothrock says. “This is a collaborative model. The seniors aren’t just guinea pigs. It empowers them and gives them some ownership in the program.”

Devito is more than happy to do that after 14 years without taking charge of her own health. Part of that blame she says is hers, but she also says her physician never pushed her hard for information and never fully educated her on potential outcomes due to her medical issues.

“You go to a doctor because you want answers and direction — at least that’s why you should go,” Devito says. “Geriatrics are not always honest about their health. They think, ‘If I have this problem or that problem and tell the doctor about it, I’m going to wind up in the hospital having surgery.’ Obviously that’s not always the case. I think this program will better prepare these students to treat geriatrics. Because I can assure you, they are going to see patients just like me, who gave very little information and thought they could handle their health on their own. I’m glad I’ve got a doctor now that will ask me questions and tell me what to do.”

Monday, December 14, 2009

Elder Care Survival Key Concern At County Forum

Courier News

Kane County, Il -- Nearly 100 Kane County elder care providers, senior citizens and their advocates discussed federal and state issues relating to elder care during a legislative forum Monday in St. Charles.

The event was sponsored by Kane County Senior Resources, Asbury Gardens, Countryside Care Center, Heritage Woods of Yorkville, and the Northeastern Illinois Area Agency on Aging.

Among challenges discussed were the state of Illinois' lagging Medicare payments to small businesses that provide elder care and services.

Betty Schoenholtz, executive director of Senior Services Associates, said state payments to elder care providers -- many of whom are small-business owners -- have lagged for months because of the state's budget shortages.

"It is of great concern to me what is happening to our (provider) agencies," Schoenholtz said, adding that those funds would help stimulate the economy through purchases made by small businesses. "When the state of Illinois doesn't pay its bills, we can't buy things from small business ... We hope (state legislators) can step up to the plate and resolve these issues."

She also recommended that legislators change state law to require the Illinois Department of Public Health to allocate at least $750,000 into the ombudsman program, or to implement a "bed fee" similar to Ohio's, which requires a $6-per-bed fee to help offset costs to agencies. Schoenholtz also said the elder abuse program is owed $134,000 from the state and that the figure represents one-third the budget for elder abuse cases.

Lucia Jones, executive director of the Northeastern Illinois Area Agency on Aging, also said she is concerned about how the state's budget issues are impacting service providers.

"The providers are all small-business owners," Jones said. "The numbers they serve are going up tremendously, because of the economy ... . There are hundreds and thousands of families in the state of Illinois in need of elder care; and if the ombudsman program is cut, those people will have to go into long-term care."

AARP spokesperson Heather Heppner also provided an update. "We have spent a very long time advocating to prevent cuts to community-based services. We know it is more fiscally responsible to care for individuals in their homes than in institutions," she said. "We have providers who have not been paid this entire fiscal year ... . Senior services need to have a heightened level of priority."

She also noted that AARP endorsed the Affordable Healthcare for America Act.

"On the House bill side, it was not perfect ... but the bottom line is that our health care system in this country is broken, and the things our AARP members have told us are important issues are addressed in that bill," Heppner said. Older adults were at times paying up to seven times more in insurance rates than younger adults, she said, and the health care act would cap age rating at two to one.

Friday, December 11, 2009

Lobbyist Working To Help Senior Citizens

Wicked Local Harvard

Deb Thomson knows all the ins and outs of Beacon Hill’s workings.

As a lobbyist for elder care and health care issues, Thomson spends her days working on behalf of a growing senior population. As a founder of The PASS Group, a legislative and administrative advocacy organization working for non-profit companies, Thomson says taking care of all its citizens is what a country should do to its best ability. Laws can get bogged down with words and requirements, but in the end, they need to serve the people in the best way possible.

For instance, Thomson is working hard for the spouses of those who need long-term care and have to put themselves into poverty to get it. A nursing home resident gets a monthly allowance of $72.80 to cover everything Mass Health does not — shoes, clothes, telephone calls, transportation, books or newspapers, said Thomson. It is a figure she finds ridiculous and wants to see increase, but it is a fight to just have it remain steady.

“This is a perilous time for human services because of all the budget cuts,” she said.

For anyone interested in lobbying work, Thomson says a good way to start is to be an aide to a legislator. A determined group of people can make a difference.

Q How did you get started in your career?

A I am an attorney and for many years, I worked as an elder law attorney and in legal services which serves lower income seniors. Part of that developed into legislative advocacy work where you pass bills and legislation that would benefit programs that elders rely on for income and health care purposes.

Q What got you started in elder services and health care?

A When I was in law school I volunteered in a clinic for elder clients. I worked for the Alzheimer’s Association for five years working on public policy. And then I left there and went into a legislative and administrative advocacy business. I had a great interest in the issues that confront the elderly in our society.

Q It sounds like you must have your ears open to everything.

A Well, I also used to work for Massachusetts law reform [agency] for several years that was devoted to advocacy on behalf of lower income people. There is a whole community out there, of which you may not be familiar, advocates and people who work on behalf of clients in nonprofit organizations trying to improve society. It is a real specialized niche in both the political and legal world.

One thing that surprised me was how small town Boston is in these circles. State government is people who change hats occasionally, so you really develop a network.

But my clients are not big corporations; my clients are advocacy groups, some small healthcare providers, and day programs for seniors. For instance, lately, there have been terrible budget cuts and they have affected most of the state-funded elder programs. There is a wait list now for health care services for elders. Councils on Aging, which rely on funding, have been affected.

Q All the cuts often seem harsh — your work must make you feel good.

A Oh, absolutely. I used to do a lot of individual representation, but this is more durable. You can pass a law that affects a lot of people. An example of the kind of issues I work on, the seniors for many years had Medicare, but no prescription drug coverage. There was a constant tension between keeping Medicare affordable and providing drug coverage.

Several years ago, they implemented something called Medicare Part B which is a drug program. But Massachusetts, at that time, had enacted a state-based program so seniors would have coverage. When the Part B coverage went into effect, prescription advantage filled the gap that Part B would not cover.

Q How does a lobbyist help them?

A It is very difficult to get anywhere without professional help. I was just at the Mass Councils of Aging annual conference talking about advocacy and how to get a bill through or how to affect a budget item. If you are just a regular layperson and you can develop a relationship with a legislator, then sometimes they can help you through the process. If you have a lobbyist it is better. If you are in a coalition of many groups, you can get the attention focused on an issue.

Q Do you sometimes feel like the underdog?

A The groups I work with do not have the wherewithal to make campaign donations. We have to make a case on its merits; we can’t make it on the fact that we made campaign donations. It has to be a compelling issue that affects the constituents of legislators and that gets their attention. Most legislators are interested in elders and their issues.

Q And it is a growing field.

A It is going to be interesting because I don’t think the government at the state or federal level is prepared to deal with the needs of baby boomers. People are getting older and saving less. The person who has pension benefits now is a rare bird.

Actually seniors take the worst hit for long-term care. Because nursing homes are not covered by Medicare, except for a very short period of care. People end up spending all but $2,000 of their assets in order to qualify for long-term care. You have to impoverish yourself to get there.

Q Elder care is not always at the forefront.

A Right. There is private long-term care insurance, but there are many problems with it. One is that it is too expensive for many people and many people wait too long until they are sick to buy it and then it is too late.

Q Is that the one thing you would like to see changed the most?

A Adequate coverage for long-term care is right up there. I guess the other thing I would like to see is better state coverage of community-based care. Again it is a question of money.

But people who live alone and are isolated really need those services.

Q How do you lobby?

A One of the important things we do is educate. We educate the legislators about the issues we care about. We educate the public about the issues we care about and we try to, at the same time, we are educating them about the importance of these issues we try to get them to advocate on their behalf.

Q So it changes all the time?

A It does. And it is fascinating. You never know quite what to expect.

Tuesday, December 8, 2009

Waiting Lists Lengthening For Elder Care Services

Somerville Journal - Somerville, MA

There are more than 2,000 households across the state that have a disabled elderly person who is not receiving home care support.

According to Mass Home Care, which represents the 27 agencies that operate the home care program locally, the waiting list to get into home care has reached 2,002 people. This includes both the basic home care program (1,593 people waiting) and the Enhanced Community Options Program (409 waiting).

Mass Home Care projects that budget cuts enacted by the General Court and the governor will result in as many as 5,000 to 6,000 seniors waiting to get home care by the close of the fiscal year June 30.

“Families will be struggling to figure out how to take care of mom or dad this Thanksgiving,” said Mass Home Care executive director Al Norman, who said the 2010 fiscal year will go down as the worst on record for cuts since the home care program began in 1974. “The irony is that nursing home doors are wide open in most parts of the state, but the door to home care is closed.”

Norman said community programs like home care are a wise investment for the state, because home care has helped drive down institutional services by 20 percent since the year 2000, and two people can be helped at home for the cost of one nursing home placement. The state’s Medicaid program is required to provide care to the disabled in the “least restrictive setting appropriate to their needs,” but Mass Home Care said the community programs are some of the first to be cut.

Along with home care cuts, the administration has recently slashed rates to the adult foster care program — a residential alternative to nursing homes — and reduced access to the personal care attendant program. The group adult foster care program has also been pared back. Cuts to these three community services total $11 million. The home care cuts totaled more than $16 million, for a total of at least $27 million in lost services.

“It will take us years to get back what we have lost,” said Norman. “We are hurting some of the most vulnerable people in the commonwealth. These are people who will show up sooner or later in our institutions, costing the taxpayers much more in the long-term. Not only is this policy forcing people to be unnecessarily segregated from their community, but it’s fiscally short-sighted.”

While these programs are struggling for every penny, the commonwealth provides $1.2 billion in corporate excise tax breaks.

Podcasts Feature Advice For Senior Community Management

Earth Times

"Best Practices in Senior Care Management" podcast series from Horst Construction discusses trends and challenges facing CEOs, CFOs and executive administrators of senior living communities. Four episodes are now online, focusing on lending and financial issues and the new Five Star rating system for senior housing.

Lancaster, PA (PRWEB) December 6, 2009 -- A series of thought-provoking podcasts developed expressly for CEOs, CFOs, executive administrators and other top decision makers of senior living communities by Best Practices in Senior Care Management and sponsored by Horst Construction is available on iTunes or accessed as an XML feed at

Titled "Best Practices in Senior Care Management," the four-episode podcast series provides ideas, processes and new information from leading thinkers and doers in the field of senior care. Topics such as new regulations, financial measures and management, marketing ideas for increasing occupancy, and operations and planning are part of the podcast curriculum.

In the first two episodes, Steve Jeffrey, regional director of Ziegler Finance, reviews first quarter 2009 results and the present state of lending and then addresses the near-future of financing and acquisitions in the senior care industry. The final episodes are a two-part discussion on the Five Star rating system for senior care facilities in the U.S. Ron Barth, CEO of PANPHA, the largest trade association representing nonprofit providers of housing and health-related service options to Pennsylvania's elderly, and Pennsylvania Secretary of Aging, Mike Hall, debate the benefits of a nationwide rating system for senior care.

The information in the "Best Practices in Senior Care Management" podcasts was originally presented at the Horst Senior Living Conference in April. The 2010 conference is scheduled for April 8 at the Lancaster Country Club in Lancaster, PA. Keynote speaker is Jim Moore, president of Moore Diversified Services, a leading national consultant to the senior housing industry. More information on the 9th annual half-day conference is available by calling 717-581-9981.

Monday, December 7, 2009

Estate Planning: Never Too Early, Often Too Little, Too Late

Yakima Herald

Eric Gustafson has seen it too many times.

Families estranged or survivors forced to spend large sums of money in the absence of an estate plan or -- just as importantly -- a plan that hasn't been updated to account for changed circumstances such as divorces or deaths.

Such plans should include a durable power of attorney for health care and finances, a will, a community property agreement for a couple and, in some cases, a revocable trust.

"It can destroy relationships if it is not well thought out and planned. You can have family members who will never speak to one another again," said Gustafson, an attorney in Yakima for 36 years and a certified elder care attorney who focuses his work now on estate planning.

"My job as an estate planner is to plan for the worst and then hope for the best," he said.

Yet only a minority of people have taken the steps necessary to see that their wishes are carried out if they die or are incapacitated.

"It amazes me how few people have an estate plan," he said.

Gustafson's experience is borne out in a 2008 poll commissioned by AARP on end-of-life issues.

The poll of more than 1,000 respondents suggests that fewer than half of people have addressed the elements of estate planning. A last will and testament had been completed by 45 percent of those who responded. But for other elements of an estate plan, slightly more than a third had a durable power of attorney or a living will that guides decisions on health care in cases of incapacitation.

People between ages 35 and 49 have a much more spotty record when it comes to estate planning. Fewer than one in three have a will and even fewer -- one-fourth -- have a durable power of attorney for health care.

The percentage of those who have completed estate planning increases with age as people acquire assets. But for younger people with children, an estate plan is even more important.

"It's important for people with children to have a will because you need to provide for children even up to 30 years old," he said. "Clearly, before they are 18 you need that to designate who you want to be guardian and not have a judge do it who doesn't know your wishes."

He said a community property agreement between spouses in a first marriage allows co-owned property to go to the surviving spouse.

"All property co-owned by the parties passes under the contract to the surviving spouse. It avoids probate on the first death," he said. "You can virtually transfer all property under a community property agreement to the surviving spouse."

Estate planning attorneys advise consumers to avoid will kits with fill-in-the-blank forms. Such kits are made generic to try to fit various laws in various states, but they may be too broad to suit a person's needs or can leave questions that must be sorted out later.

"Planning an estate can be a very complex thing depending on what is going on," observed Steve Hartnett of San Diego, the associate director of education for the American Academy of Estate Planning Attorneys. "A proper estate plan integrates all aspects of a person's goals with their assets."

AARP advises against people sitting down at the kitchen table and writing out their own will because of the chance for errors that cause problems later. Few states recognize homemade wills, according to the organization.

But short of an estate planning attorney, there is help available online and the field is growing., a personal finance Web site, reports that some sites offer users access to an attorney to check your work. Others don't.

Prices can range from as little as $20 to as much as $225.

But discourages those who have significant assets, own a business, have children or are in a second marriage from going the online route.

Financial planners are great at helping clients develop an investment plan, but they lack the expertise to deal with estate plans.

If you use an estate planning attorney, anticipate preparation of an estate plan taking from a month to six weeks to complete.

Keeping the estate plan up to date to allow for changes is also important.

Gustafson recalls one case in which a client whose elderly aunt lived half a state away put her neighbor on her checking account to pay bills and purchase groceries. The aunt, suffering with health problems, also transferred funds from investments to cover medical bills.

When the aunt died, the neighbor received a substantial sum of money as a joint tenant of the checking account.

The money had been intended for Yakima relatives in the woman's will. But having the neighbor's name on the account trumped the will.

"We see it all the time where family members put someone on their bank account or trust account. It changes the legal consequences of where that asset goes," he said.

Beneficiary designations on life insurance and retirement accounts also prevail even if a will prepared years later names a spouse.

And if no estate plan exists, a person who dies intestate -- as the lack of a will refers -- will have the laws of the state determine what happens to their assets.

"You want to control where your assets go," Gustafson said.

Hartnett agreed, saying those who die without a will may have wanted assets to go to a domestic partner, a friend or a charity, none of which is accounted for in state law.

"The best solution is an estate plan that is tailored to your circumstances. While the intestate provisions may satisfy a small number of people, they don't accomplish the goals of the ordinary person," he said.

Based on his experience, Gustafson said he believes people delay taking action because they don't want to face their own mortality or are concerned about cost. But costs for a plan that covers all assets are often lower than buying annual homeowners and auto insurance.

He estimates an average couple can have a qualified estate plan -- with key documents included -- for $600 to $1,000.

"The least cost is when you do good planning," he added.

Choosing Appropriate Senior Care

Evansville Courier & Press

One of life's landmarks is choosing a nursing home. It should be carefully thought out, but typically the decision is made when a loved one is about to be discharged from a hospital, often with hours notice. Even on that deadline it's possible to make a good choice.

Lee Bowman, medical reporter for Scripps Howard News Service, talked to many top experts on nursing homes to come up with some guidance.

They recommend starting with the U.S. Centers for Medicaid and Medicare Services' Nursing Home Compare, a database that ranks 15,700 nursing facilities on a star system, from one star — "much below average" — to five stars — "much above average." Around 12 to 13 percent of nursing homes have the top rating; slightly more than 20 percent the lowest.

But the star system can be slightly misleading. In a study of the CMS database, Scripps Howard came up with a few general principles to help read between the ratings:

— Homes run by nonprofits, about two-thirds of all, generally score better than those run by for-profits and tend to have more nursing staff per patient.

— Homes with more than 100 beds tend to get lower scores in all categories.

Experts recommend finding a nursing home close to the patient's home because it's easier for family and friends to visit. He recommends meeting the home administrator and making several visits at different times to talk to staff and inspect public areas. Look for longevity among the key caregivers. If more than 25 percent of staff are recent hires, it can be a worrisome sign.

Plan early. Choosing a nursing home is difficult, but knowing the patient's preferences improves chances that the decision will be the right one.

Couties Considering Phase-Out Of Home-Health Care

the Daily Mail

CATSKILL — With Greene County looking to get through one of its most difficult financial times in recent memory, one program that is facing eventual elimination is the CHHA — certified home health agency — which is provided by the Greene County Public Health Department.

While a final decision has not been made, the Greene County Legislature is currently considering phasing out the CHHA, which provides in-home nursing care to recently discharged patients.

“The majority of our patients are Medicare patients, so they are over 65 and homebound,” said Public Health Director Marie Ostoyich. “They are referred to the certified home health agency through the hospital or nursing home upon their discharge, and they need assistance with things like medication management, dressing change, or some kind of skilled nursing care at home.”

Eliminating the CHHA would save taxpayers approximately $800,000 a year, once it has been fully phased out. The first year of the phase-out program would save around $400,000.

However, county officials say care for current patients would not be impacted, and that the program would be phased out slowly over a period of two to three years.

“It would probably take several years to phase out the CHHA,” said Interim County Administrator Dan Frank. “A lot of people are under the impression that if they are currently getting care under CHHA they would be cut off, but that is not true. We would probably slow down the intake of new patients, and eventually stop it.”

Referrals for care generally cover a sixty-day period, and then need to be reissued should the patient continue to have a medical need for home health care. They would not be affected by the change, should it go through.

“For patients who are getting care right now, their care would continue for as long as it is needed,” Frank said.

Another group of residents who would not be affected by the phase-out of the CHHA are seniors who receive services through the Greene County Department for the Aging. Day-to-day care provided to those senior residents is not part of the phase-out proposal.

One option the county is considering to continue offering in-home care post-discharge is having private nursing agencies take over. Currently, some patients already receive care through The Eddy Nursing Service.

“Another option we could look at would be to have private industry take over the CHHA and let them operate it,” Frank said. “We are very concerned that people have alternatives. A segment of the population is already being served by private industry, so we could look at privatizing it.”

One problem with that option is that The Eddy currently does not provide service to communities on the mountaintop, and the needs of those clients have to be addressed as well.

Frank said the slumping economy has presented the county with serious financial challenges this year, and that it’s expected that things will only get worse over the next year or two. Implementing changes to the CHHA — or any other county program — is one way officials are looking to trim costs, but it’s a balancing act.

“Before we make a decision regarding the CHHA, we have to consider the best interests of our residents,” Frank said. “This will be a very difficult year for the legislature to decide the budget because they will have to balance the financial needs of the residents with the service needs of the residents. We are getting crunched in every direction.”

With the economic stakes high, officials say they want to minimize the tax burden on already stressed-out taxpayers. Frank said they are doing that by cutting expenses as much as possible. Much of that was done in the 2008 and 2009 budgets, and now that the easy changes have been made, the legislature is left with making some tough decisions on programming and services.

“We understand our residents are under a lot of financial pressure — unemployment is high, tax delinquency is up — so adding more tax to that would be difficult,” he said. “The county is already making substantial cuts to staffing — we eliminated positions, and we are proposing more cuts. There are no pay raises, and we are asking our employees to do more but we aren’t giving them more. Now, we need the agencies to share in the pain.”

Saturday, December 5, 2009

Mysteriously, Risk Of Stroke Shown To Have Geographic Determinants

eMax Health

A new study published in the December issue of Neurology reports on the strong influence of birthplace on stroke risk. A person born in the “Stroke Belt" will continue to have a higher risk of stroke even if they have moved away.

M. Maria Glymour, ScD, of Harvard School of Public Health, and colleagues evaluated stroke mortality rates for United States–born black and white people aged 30–80 years for 1980, 1990, and 2000. This data was defined by birth state, state of adult residence, race, sex, and birth year.

Four “Stroke Belt” (SB) exposure categories were defined: born in a SB state (North Carolina, South Carolina, Georgia, Tennessee, Arkansas, Mississippi, or Alabama) and lived in the SB at adulthood; non-SB born but SB adult residence; SB-born but adult residence outside the SB; and did not live in the SB at birth or in adulthood (reference group).

The researchers findings noted an elevated stroke mortality associated with both SB birth and, independently, SB adult residence. The highest risk was found to be in persons who were born in the SB and continued to live there as an adult.

For African-Americans born in the Stroke Belt and living there as adults, the odds ratio for stroke mortality was 1.55 in 1980, 1.47 in 1990, and 1.34 in 2000. For white individual in the same group, the odds ratios were 1.45 in 1980, 1.29 in 1990, and 1.34 in 2000.

For reasons that have eluded explanation, residents of the southeastern U.S. historically have had a 20% to 50% greater risk of stroke mortality compared with residents living elsewhere in the country. This influence of residence in the Stroke Belt has little association with conventional stroke risk factors, social resources, or access to medical care.

Future studies of stroke risk should include detailed information about movement from one region to another. Such information might show whether people who move have different risk patterns help identify more precisely the point in life when stroke risk begins to increase. That information could aid the development of risk-reduction strategies specific to different regions of the country, the authors concluded.

Senior Care Across The Miles

The Bend Bulletin

Our society has become increasingly mobile in the past few decades.

Kids move away from home and don’t come back. Parents retire to another state. Family members shift from place to place, looking for work, going to school, building their lives.

Often, adult children end up living some distance from their aging parents. While this leads to increased travel and decreased time spent together, it has another consequence as well. Distance makes it harder to help when a parent is in need. As a result, many adults are finding themselves playing the role of long-distance caregiver.

Raeann Hamon, a professor of family science and gerontology at Messiah College in Pennsylvania, says long-distance caregiving is absolutely a trend that is likely to increase.

“Certainly, as the baby boomers and their parents age, we can expect a large jump in the number of families dealing with such caring across miles.”

These adult children face challenges of trying to find the right role to play, staying involved while not becoming overly burdened.

Starting off

Nancy Turk co-owns Visiting Angels, a local service that connects in-home professional caregivers to older individuals. She says about half their clients have relatives in another region or state. They have been contacted by family members in Alaska, California and Australia who want to hire help for a local relative. Typically, Turk says, a family member realizes they need to step in after visiting. “They are shocked to see the condition their grandparents or parents are living in.”

These relatives, often adult children, believe their parents are doing fine, but the reality is somewhat different. They might find rotten food or dog feces. “It’s traumatic for the kids.”

Turk says oftentimes the family members feel guilty and then hire staff to come in and assist, particularly in cases in which the parents don’t want to leave their own home.

Marion Somers, a geriatric care manager and author of “Elder Care Made Easier,” suggests adult children think about what they can and cannot do. She encourages them to set limits and to delegate. “You have to be honest about your time and resources.” She thinks of it this way: It’s like being on an airplane when passengers are supposed to put on their own air masks first before helping anyone else.

“You have to be organized, you have to prioritize, you have to delegate,” Somers said.


Trying to assist a relative living far away can be quite complicated. Hamon says many adult children feel guilty about not being able to help more, while also feel angry about the imposition and feel anxious about future needs. She says many individuals feel guilt because of the “norm of reciprocity.”

“There’s the notion that you should be good to those who have been good to you,” Hamon said.

Figuring out when to visit and to allot resources — both financial and time — is another big issue. Sometimes, resources are better spent hiring someone to help than flying out to visit for a week. Somers point out that a $600 plane ticket could be used to hire someone to come in once a week to help out for a couple weeks or more.

Robert Sachs knows about this challenge from both sides. He has been a caregiver working with adult children who live in another state. And he has been the son, living far from his dying father. His experiences are chronicled in his book “Perfect Endings.”

“We’ve created this kind of quandary for ourselves.”

When Sachs worked in a hospice in New Mexico, he saw many negative reactions from staff to adult children living far away. He says staff members frequently looked on these individuals negatively, thinking, “If you really cared, you would live here and be here all the time.”

Sachs felt these assumptions were unfair. That said, he recognized why it happened. Sometimes, the professional caregiver felt as if the relatives living away were serving as armchair quarterbacks, questioning decisions and making recommendations without really knowing the situation.

Sachs says relatives’ top priority should be to develop a relationship with the primary professional caregivers.

Hamon says it’s also not good to assume an older parent will naturally move to where adult children live. She believes part of it is generational because many older individuals have lived in one place for many years. They can also be entrenched in the community and have social support. “To ask them to move, it’s a challenge.”

Practical steps

Hamon suggests adult children start regular rituals and routines, for instance calling once a week at the same time and day.

Somers agrees, saying, “The voice tells so much. Most older people don’t have the energy to fake it.”

When the son or daughter does visit, they need to really get to know the area. Hamon suggests they learn about the neighborhood and meet the neighbors. Who does the older relative have regular contact with? She suggests the child hand out his or her phone number and ask for theirs. Then if neighbors see anything of concern, they will know who to call. She also thinks adult children should try to assess their parents’ needs, such as help with household tasks, personal care and transportation.

Somers suggests adult children take a “look at the house or apartment with fresh eyes.” What is the lighting like? How is it at night? Are any light bulbs burned out? How easy is the bathroom to navigate? Are there any throw rugs? What about the outside, including the garage and porch? She strongly encourages installing grab bars in bathrooms, putting in sensor lights outside and getting rid of all throw rugs. Somers also believes all kitchen items should be at eye level. She says to banish footstools. She will hire a neighborhood kid to mow the lawn or shovel snow. She also encourages family members to get in touch with the parents’ church, if applicable. Getting the grocery store to deliver is another good option.

Hiring help can bring relief. Turk says many adult children appreciate being able to talk with someone who serves as their eyes and ears.

Turk says sometimes the older individuals may resist outside help, saying, “We don’t need it; we’re fine.” They see help as a sign of the end. Sometimes, however, they “respond better to someone who is not a loved one,” said Turk. With family, older individuals may feel more comfortable saying no or getting angry.

Adult children need concrete information should anything go wrong. This includes a list of their parents’ doctors, medications, insurance information and more. Knowing what they are allergic to, past surgeries, medical issues and what vitamins and over-the-counter items they take are also good ideas.

Not all parents expect their children to be there to provide physical care for them, says Hamon. “Most expect their children to be emotionally supportive.” That is the most important piece. And the good news, according to Hamon, is being a good listener and offering support “is something that’s a bit easier to do at a distance.”

Using The Internet To Transform Elder Care

Wicked Local Concord

Concord resident Jim Reynolds last month opened Caring Companion Connections, a home services agency that adds a 21st century twist to in-home elder care.

CCC’s caregivers, known as Companions, use smartphones, such as BlackBerrys, to upload photos, activity logs and daily reports to a Web portal tied into a landline at the client’s location and viewable by loved ones in other cities or towns.

Reynolds has hired Debbie Bier as district director of the Concord office. She is responsible for day-to-day operations of Caring Companion Connections, which covers Metrowest, a 45-minute radius around Concord by Reynolds’ definition.

He also plans to open offices in the Falmouth area, which would cover the Cape and South Shore, and on the North Shore around Salem or Gloucester. But Reynolds, whose family operates large non-medical home care agencies in Florida and Kansas, expects Caring Companion Connections will grow beyond Massachusetts.

Tell me about your business.

This is a family business, me and my family. We provide flexible, reliable homecare services to elders who want to remain in their homes as long as they can and stay independent rather than move into a nursing home. My dad started this business 17 years ago, but we have added in as new a feature here in Concord, a Web communications portal, which is unique in the industry. And this allows family members, especially adult children who are far away, to log on at work, or during the day from home, or on a business trip, wherever they are and see the status, to get a window into the living room, of what’s going on at the parents’ house. They know when we log in. They know the activities, meals and medication reminders. That kind of thing.

Why is the Web communications portal so important?

That’s important because typically, in this industry, that information is kept on a logbook on the kitchen table, and it’s useful if you’re standing at the kitchen table. The problem is that in most families the person who needs the information is not at the kitchen table — they’re usually in another city. If their loved one gets ill, or is not taking medications or having trouble moving — any information that needs to be noted — the information doesn’t get where it needs to be as quickly as it should. And even then, only one person has it and you wind up with a range of telephone calls and e-mails and voicemails. So this provides one place, that’s instantaneous, that everyone can go for access to the same information and make decisions and take actions as quickly as possible. Or, even, if no action is required, simply to know that everything’s OK.
Can you talk about who your clients are and what kind of care they require?

There’s a particular phrase in this industry, activities of daily living, or ADLs, and those can range from things like trips to the grocery store to help getting to doctor’s visits to medication reminders and meal separation to more personal things like help with grooming, or help in the bathroom. If someone has limited mobility, and can’t move easily, we can help. If someone has lost use of a limb because of a stroke we can help. If someone is a risk to walk because of dementia, we can help. Typically, the clients are someone in their retirement years, most of them live alone and it’s important for these people to live where they want to live, a place that is familiar, where they have often lived for decades. Statistics bare out that people who live where they want to live have much better healthy, happy retirement years, and people who are involuntarily moved do poorly medically and have much more depression and report being less happy.

The Modern Dilemma Of Elder Care: The Sandwich Generation

New Jersey Newsroom

More than 25% of American families are involved in elder/parent care at some level. Today, the baby boomers are the "heart" of the sandwich generation.

To understand the significance of the Sandwich Generation, one needs to realize that the Sandwich Generation is THE largest segment of our population.

Who are these sandwich generationers?

Traditional sandwich: those sandwiched between aging parents who need care and/or help and their own children

Club sandwich: those in their 50s or 60s, sandwiched between aging parents, adult children and grandchildren. OR those in their 30s and 40s, with young children, aging parents and aging grandparents. (Term was coined by Carol Abaya)

Open Faced: anyone else involved in elder care. (Term coined by Carol Abaya)

Statistics further demonstrate the importance of understanding the sandwich generation scenario:

$34 billion a year are lost in employee productivity because of elder care responsibilities. More productivity is lost from elder/parent care responsibilities than from child care.

The cost to industry to replace experienced workers who leave their jobs to take care of a sick loved one is more than $7 billion a year.

Of full time employees who are caregivers, today 52% are men and 48% are women. This is a dramatic shift in the caregiver picture because of the high rate of divorce and family being geographically scattered.

77% of caregivers report they work less effectively.

More employees develop health problems from the stress of elder care than from child care.

While the sandwich generation is the largest segment of our population, those over 85 make up the fastest growing segment.

All of these statistics clearly show the undefinable challenges for adult children.

If you are a sandwich generationer, know you are not alone. In order to keep the stress level of sandwich generationers managable, there are a number of important elements that must be understood. These will be addressed in future columns.

A key sandwich generation responsibility is to enable and empower a parent to live as independently as possible as long as possible given true physical and mental capabilities. A sandwich generationer should NEVER take over control of a parent's life and should do as little as necessary to maintain an elder's safe environment and health.

Acknowledge and accept the fact that everyone's emotions will be on a roller coaster forever. As soon as a sandwich generationer thinks things have calmed down, a plunge is inevitable.

No sandwich generationer should do everything alone for an aging parent. This leads down the road to a sandwich generation physical and mental breakdown. Help from other family members and community resources should be identified and used.

Legal, financial and quality of life elements MUST be addressed BEFORE a crisis. If a person (regardless of age) does not protect himself or herself by executing key legal documents, a court can appoint a complete stranger to take over finances, medical decisions, and lifestyle decisions.

Spiritual elements are also important in an elder's everyday life and especially in relation to dying.

Sunday, October 4, 2009

Canada Shifting Senior Care Away From Hospitals

Story from Calgary Herald

CALGARY - Alberta Health Services have announced a three-year plan to add almost 800 "community living options" in the province for senior patients - who would otherwise crowd hospital beds, officials said.

Dr. Stephen Duckett, the provincial body's president and CEO, added that there will be no healthcare staff layoff announcemnts today, and there will be none until Alberta Health Services work through its current care plan.

"The key thing here is that, not only did we identify where we want to go, but also how to get there," Duckett said during a press call at noon. "This is not vapourware, as you call it... it's a concrete thing."

The plan, Duckett says, is to invest about $13 million in both the Calgary and Edmonton CMA to expand community care. The new spaces - about 775 between the two metropolitan areas - will include home care, supportive living and long-term care facilities.

The move of seniors who don't need acute care will allow health officials to free up hospital beds, Duckett says. Officials estimate the shift to community care would save up to $50 million for the cash-strapped provincial body.

Doctor Files Supreme Court Case Vs. BCBS of Texas

Story from California Newswire

Dr. Dralves Edwards, a board-certified family physician in Dallas today filed a civil case in the U.S. Supreme Court against Blue Cross Blue Shield of Texas, the contractor for Medicare. For the past 13 years, Edwards has challenged the integrity and unethical practices of Blue Cross Blue Shield (BCBS) and is confident that the U.S. Supreme Court will rule in a responsible way such that every Medicare provider and patient benefits.

In 2003, the original suit was filed in Dallas district court alleging that BCBS engaged in fraud, gross negligence, and criminal acts that, according to Edwards, forced him to close his doors. Today, he works as a hospital emergency room physician.

BCBS responded to the suit by removing it to federal court, but the case was remanded back to district court. BCBS then filed a “No Evidence” Motion for Summary Judgment that was granted sovereign immunity by the lower courts.

Edwards acknowledges that lower court decisions have historically disagreed with well established U.S. Supreme Court cases (i.e., Ardary vs. Aetna; Heckler vs. Ringer; and Kelly vs. Advantage Health, Rochester vs. Travelers).

In 1997, Edwards says BCBS caused irreparable harm to his thriving practice and marred his professional name when he was placed on a 100 percent prepayment review. For three consecutive years, 96 percent of his claims were denied; his practice was 90 percent Medicare.

“I provided free transportation and made house calls that saved Medicare millions of dollars,” reports Edwards. “These were patients who probably would have ended up in the emergency room.”

In October 1996, Edwards was featured in USA Today as, “One of the few doctors in America making house calls.”

BCBS denied most of Edwards’ claims as “non-covered services and not reasonable and medically necessary.”

Medical conditions like breast cancer, diabetes, and decubitus ulcers were denied. However, after the course of five years, claims were appealed through Medicare’s administrative process and paid.

“Something was terribly wrong,” Edwards says. “Other doctors were being paid by BCBS for these same medical conditions, but payment continued to be denied to me.”

Edwards alleges that, “BCBS was tested for profiling and got caught.”

He explains what happened. One doctor employed by him applied for a new Medicare group number. Dr. Edwards’ name was deliberately left off of the original application. The group number was granted, 300 claims were submitted, and BCBS paid 98 percent of them. A month later, Edwards’ name was added, 300 claims were submitted and all were denied.

BCBS told Edwards he had a documentation problem. However, after meeting with a Medicare representative to review the denied claims, no problems were discovered. It was recommended that he sign his progress notes and resubmit the claims for payment. He did and they were still denied as “non-covered services and not reasonable and medically necessary.”

Edwards then obtained the list of 100 doctors on the prepayment review list for 1997 through 1998. He contacted most all of these doctors and discovered that they knew nothing about a “prepayment review.”

“This evidence was highlighted in the suit, but ignored by the courts,” says Edwards.

It was becoming apparent that some unethical practices were in play.

To date, this 13-year ordeal has led to thousands of dollars spent; countless hours; a five-year administrative process; five summary-judgment hearings; numerous investigations; nine attorneys; 19 judges; a 100 percent prepayment review; and protectionism from the lower courts.

“Justice for the innocent has not been served,” Edwards says. “The guilty remain in business. Right now, it rests in the hands of the U.S. Supreme Court.”

BCBS Vs Chiropractors

Story from AIS Health

Chiropractors Bent Out of Shape Over Blues’ Post-Payment Denials

The Blue Cross and Blue Shield Association (BCBSA) and 22 Blue Cross and Blue Shield (BCBS) plans were named as defendants Sept. 11 in a class-action suit alleging they engaged in “abusive practices in using post-payment audits and reviews.” The suit contends that Blues plans made improper repayment demands “to pressure providers to repay substantial sums that have previously properly been paid as health insurance benefits for services provided to BCBS subscribers.”

Providers Want Recouped Funds Returned

Pomerantz Haudek Grossman & Gross LLP and Buttaci & Leardi LLC filed the suit on behalf of the Pennsylvania Chiropractic Association (PCA), the New York Chiropractic Council (NYCC) and the Association of New Jersey Chiropractors as well as 15 independent providers. Hundreds of millions of dollars could be at stake, said co-counsel Vincent Buttaci, who pointed out that BCBS plans’ anti-fraud efforts in 2008 resulted in more than $350 million in recoveries and savings for the plans. He adds, “We believe a substantial portion of this ‘recovery’ falls within the improper practices we are challenging in this action.”

According to the suit — filed in U.S. District Court in Chicago — the post-payment actions are in violation of the Employee Retirement Income Security Act of 1974 (ERISA) and the Racketeer Influenced and Corrupt Organizations Act (RICO). The suit contends that the Blues are in violation of ERISA because the “repayment demands are retroactive determinations that particular services are not covered under the terms of the BCBS health care plans,” and the demands lack a proper appeal process or other protections available under ERISA for both self-funded and fully insured health care plans offered through private employers. The suit also alleges that the insurers’ post-payment audit and review process and “forced withholds of unrelated benefit payments to offset alleged prior overpayments” violate RICO.

The suit seeks an undetermined amount of money. According to the filing, the “Plaintiffs seek appropriate declaratory and injunctive relief to enjoin Defendants from pursuing their effort to coerce recoupment and, further, to order Defendants to return any funds they have received or withheld from Individual Plaintiffs and members of the Classes as a result of their recoupment efforts.” It also seeks interest on the withheld funds.
The suit contends that Blues plans made improper repayment demands “to pressure providers to repay substantial sums that have previously properly been paid as health insurance benefits for services provided to BCBS subscribers.”
Plaintiff’s counsel D. Brian Hufford of Pomerantz tells The AIS Report, “In essence, the BCBS entities are alleging overpayments and then just taking the money from the providers, without valid due-process protections. We believe this is a blatant violation of law.” According to Hufford, some chiropractors have tens of thousands of dollars because of the plan’s alleged repayment practices.

He adds, “We believe they’re withholding money even in situations with self-funded plans when they didn’t pay for the treatment.” And the insurers, he alleges, haven’t repaid the plan sponsor for the money withheld from the provider in these instances.

“We met on numerous occasions with Blues senior management [at Highmark, Inc. and Independence Blue Cross] in an effort to establish a fair and balanced approach to conducting post-payment reviews, but to no avail,” said PCA Executive Director Gene Veno.

According to Pomeranz, BCBSA “is coordinating the recoupment efforts with its state BCBS licensees on a nationwide basis.” The plaintiffs, the law firm adds, seek to enjoin Blues plans from “continuing to engage in impermissible audit and recovery practices and to compel them to return the funds they have improperly withheld.”

BCBSA spokesperson Kelly Miller said the association does not comment on pending litigation. The 22 Blues plans named in the suit are: Blue Cross and Blue Shield of Rhode Island, Blue Cross and Blue Shield of Alabama, Arkansas Blue Cross and Blue Shield, Blue Shield of California, Blue Cross and Blue Shield of Florida, Blue Cross and Blue Shield of Georgia, Health Care Service Corp., Blue Cross and Blue Shield of Kansas, CareFirst Inc., Blue Cross and Blue Shield of Massachusetts, Blue Cross and Blue Shield of Minnesota, Blue Cross and Blue Shield of Kansas City, Horizon Blue Cross and Blue Shield of New Jersey, Excellus Blue Cross and Blue Shield, Blue Cross and Blue Shield of North Carolina, Highmark, Inc., Blue Cross and Blue Shield of South Carolina, Blue Cross and Blue Shield of Tennessee, Premera Blue Cross, The Regence Group, Wellmark, Inc., and WellPoint, Inc.

The NYCC and the ANJC had previously joined in a class action filed Aug. 4 against Aetna, Inc. regarding similar post-payment audit practices.

Some Exercise Their Right To Opt Out Of Health Insurance

AP Story

NEW YORK — Call it a health care gamble: the decision by some people to opt out of health insurance, paying cash for routine care while playing the odds that an accident or catastrophic illness won't plunge them into financial ruin.

President Barack Obama's goal of requiring everyone to carry health insurance has drawn a great deal of skepticism from this group. Many pay far less for health care than they would on premiums, and doubt that insurance would even cover them if they needed it.

It's unknown how many of the nearly 50 million uninsured in the United States voluntarily go without coverage. Researchers at the Kaiser Family Foundation, which studies the uninsured, said most are young, generally healthy adults who are self-employed or in relatively low-wage jobs that do not offer insurance coverage and don't pay enough for workers to afford individual policies.

"Income is key and most of the uninsured have low incomes," foundation researcher Karyn Schwartz said. "If you look at your budget and think you can't afford it or can afford it if you eat only ramen noodles, you may choose not to get it."

All the health care plans that have emerged from the Democratic-controlled Congress would require everyone to have insurance, the way drivers in nearly every state must purchase auto insurance. Proponents say that by bringing everyone into the system, medical risk is spread over a broader population, bringing costs down.

Those who opt out voluntarily might have to pay a penalty. Sen. Max Baucus, D-Mont., who drafted the Senate Finance Committee's plan, set the penalty at $3,800 for a family but cut it to $1,900 amid complaints that the original level was too high.

Republicans have called the insurance mandate a new tax on the middle class. Obama disputes that, saying that whatever plan emerges from Congress must offer subsidies to lower-income people that will make coverage affordable.

In exchange for the requirement that everyone buys coverage, Obama wants a guarantee from insurers that they no longer will deny coverage based on an individual's health or drop coverage when a person gets sick. The insurance industry has signaled it will accept that trade-off, but needs to convince skeptical consumers that it actually means it.

Doubts about what insurers will cover — coupled with the high cost of premiums — have driven some to opt out and take their chances.

Krista Neher, who's starting her own social media and marketing venture, is one.

The 30-year-old from Cincinnati recently left Procter & Gamble Co., where she was covered by the company's health care plan. After researching the costs of an individual policy, she decided to remain uninsured.

"I want to have health coverage, I think it's important. It bothers me that I could be hit by a car," Neher said. "But I have really low confidence that any insurance company would even cover me in that case, even after I paid all the high premiums. It just seems like a lose-lose situation."

Many people who go without coverage have found that health care providers often will cut the price of a procedure if they know they'll be paid in cash rather than through insurance.

Jason Jepson, a self-employed communications consultant based in Southern California, decided against buying an individual policy he said would have cost twice as much as his $1,250 monthly rent. He pays out of pocket for all medical treatment, saving money even after being treated for a broken ankle and severe strep throat.

"If you pay with cash, they do give you a discount — it's the big secret of not having insurance," Jepson, 35, said.

But Jepson said his lack of insurance has meant lifestyle adjustments, such as driving less and staying off freeways to avoid accidents. He says he supports Obama's requirement that everyone carry insurance if it can be made affordable.

"I would pay for it. I'm just not sure it will really cover everything," Jepson said.

To ease fears of an unexpected medical crisis, registered nurse Mary Pitman of Vero Beach, Fla., refuses health insurance and takes the extra cash in her paycheck. Pitman, 54, puts $3,000 per year into a pretax flexible spending account for routine care and another $300 per month in an emergency fund in the event of a major illness.

"I have more control over my money this way, and there's a tax advantage," she said.

As skeptical as many are about insurers, some are equally doubtful about government's ability to do a better job managing health care.

Laura Silverthorn of Tampa, Fla., left a nursing job to start her own business designing and selling temporary tattoos. She and her toddler son have gone without health coverage for nearly two years.

While Silverthorn, 36, said she wishes she could afford insurance — "Just one accident and you're done," as she put it — she's also grown disillusioned with government-run programs after working part time reviewing medical charts for Medicaid.

"I don't know if I want the government running health care when I see how they run Medicaid — there is so much fraud," she said.

The only test case for Obama's plan to bring everyone into the health insurance system is Massachusetts. In 2006, it enacted a program to cover all state residents. Those who opt out must pay a $912 annual tax penalty.

Michael Widmer, president of the nonpartisan Massachusetts Taxpayer Foundation, which researched the effectiveness of the state's health insurance mandate, said most people chose to buy insurance rather than pay the penalty — even those who are "young, healthy and immortal."

"Most are saying, 'If I'm going to have to pay this much in any case, I should be covered,'" he said.

While about 65,000 people in Massachusetts were allowed for financial reasons to opt out of the mandate last year, the state now has the lowest rate of uninsured residents in the country — 4.1 percent, according to the latest census data.

Thursday, June 18, 2009

Moving Closer To Acceptable Public Health Plan
Senator Kent Conrad (D-ND) Introduces a "potential compromise" to the public health plan. Following is an interview with Ezra Klein of the Washington Post.

(Earlier today, Sen. Kent Conrad, the North Dakota Democrat who chairs the Senate Budget Committee, introduced a "potential compromise" on the public plan: A system of federally-chartered co-ops that could offer a non-profit alternative to the for-profit insurance industry. In this telling, the co-ops preserve the central feature of the public plan -- they're a competitor to the traditional insurance industry -- but are free from the baggage of government control.

I spoke to the Senator this evening about the co-op model, and he said a few things that surprised me. First, his search for an alternative was on behalf of the G-11 -- the key Senate powerbrokers on health care. Second, it proceeded from the premise that the public plan doesn't have the votes. All Republicans are opposed and, according to Conrad, "at least three Democrats." And third, he thinks reconciliation is basically out as a viable option for comprehensive health reform. A lightly edited transcript follows.)

Tell me a bit about your idea for chartering co-ops in the health insurance market.

Maybe it would be most useful to tell you how I got into this. The G-11 group, which is the members of the Senate, Republicans and Democrats, chairmen and ranking members of the key committees, who've been given the overall responsibility to coordinate health care reform in the Senate, asked me 10 days ago to come up with something to bridge the divide between those who are strong adherents to the public plan and those who are strongly opposed.

The co-op structure came to mind because it seems to fulfill at least some of the desires of both sides. In terms of those who want a public option because they hope to have a competitive delivery model able to take on the private insurance companies, a co-op model has attraction.

And for those against a public option because they fear government control, the co-op structure has some appeal because its not government control. It's membership control, and membership ownership.

Also the co-op model has proven very effective across many different models. Ocean Spray in the cranberry business, and Land of Lakes in the dairy business, and Puget Sound in the health care business.

How do you respond to someone who says, this is a terrific idea. More competition is always welcome. But why instead of a public option? Why not do it alongside and let a thousand coverage models bloom?

Votes. The problem is this. If you're in a 60 vote environment in the Senate -- and I believe we are, because I believe reconciliation simply won't work -- if you begin tallying up the votes, I believe that virtually all Republicans are against the public option and some democrats are. So how do you get to 60?

How many Democrats would you estimate are against a public option?

I don't know for certain, but I think at least three, and maybe more.

And why do you think that reconciliation won't work for health reform.

Reconciliation was never designed to write substantive legislation. It was designed solely for deficit reduction. The whole idea was you would change numbers, not policy. You would change numbers on the revenue side of the equation and the spending side of the equation.

And so, the way it works, under current rules, if you're in reconciliation, you have to be deficit neutral over five years. Under the budget resolution, health care can be deficit neutral under 10 years. That's a big difference.

Two, under reconciliation, you're subjected to the Byrd rule. The Byrd rule says that anything that doesn't cost money or save money, or that only costs money or saves money in a way that's incidental to the policy, is subject to strike. The result, for instance, is that all the insurance market provisions are subject to strike. All the wellness and prevention provisions are subject to strike. The Senate parliamentarian said to us that if you try to write substantive health reform in reconciliation, you'll end up with Swiss cheese.

Then let's go back to why this works as a compromise. I understand why it would be preferable for Republicans. But for supporters of a public plan, the key advantage is that the public plan is big. It can negotiate discounts with providers. In the form Sen. Rockefeller offered, it can even use Medicare payment rates. These co-ops don't seem like they'd have that size or weight. How would they compete with large private insurers?

They might have that weight. One option is for a national cooperative. That would give it the heft and weight to compete. But you know, one of the interesting things when we talk to experts is that they say critical mass is probably around 500,000 members. Puget Sound is probably around 580,000 and they compete successfully against much larger entities. The experts tell us that there are probably advantages of size up to a point, but after that point, the law of diminishing returns sets in.

Who would charter these? What is the process? Do I go over to my local health insurance exchange and put in an application?

The way co-ops typically are formed, people who feel they're not appropriately served, or not served at all, band together. They form an organization, elect a board, hire people to do the work, pool their money, and the organization goes forward.

These cooperative entities would provide their contracts through the exchange just like everyone else, be subject to the same rules as everyone else, in terms of reserve requirements, in terms of what kind of contracts they could offer. People would go to their exchange, they'd see the option, and if they liked it, they'd sign up, and then they become one of the members, because every member is an owner. And they would have elections and that elected board would choose the leadership.

Would there be regulations on how many of these there would have to be in each state?

We've not contemplated having that in the health care reform law, but there is clearly an economic requirement in order to have the leverage to negotiate with providers to get competitive rates, you need greater bulk. That's where we believe we need 500,000 lives to be competitive.

That's probably one of the two major items of discussion still remaining here. They're various options for consideration if you will. I offered the G-11 group three models. One is state-based, so every state has one. I don't think that works frankly. In states like mine, the pool wouldn't be big enough. The second would be a national entity. That's probably too limiting as well.

What you probably need is a national entity with state affiliates, and the further flexibility so those states can have regional pools. So in our part of the country, you might have North Dakota, South Dakota, Montana, and Wyoming go together. Out east you might have Maine, Vermont, and New Hampshire together. We're consulting with experts tomorrow about that.

Where did this idea come from? I've done a fair amount of health care reporting, and this is the first I've heard of it.

I guess it came out of conversations in my office after we were asked to see if we couldn't come up with some way of bridging this chasm. Part of it is that we're so used to cooperative structures in my state. They were begun by progressives, they came out of the progressive era. And they're so successful in our state. So I can't really say we came up with some brand new idea. We just thought about our own experience.

What has been the reaction of some of your more liberal colleagues to this?

I think it's fair to say mixed. Those who really want public option because they really want single payer, this does not satisfy their position. Others who really want a competitive insurance model kind of like it. Others who are looking at how you put together the votes are intrigued by it. And on the Republican side, a grudging acceptance that this may be one way to increase competition that does not increase government control.

Let me ask you one last question on that. I understand why this proposal wouldn't satisfy liberals who want single-payer. But why does it arouse Republican opposition? It seems, in a way, to be very small-r republican.

Because they don't...ah, you know, you'd have to ask them. It would just be my surmise on why some of them don't like it. They really don't want a competitive model, at least some of them.