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Tag: PACE

  • How former CMS head, Tom Scully, privatized and destroyed Medicare

    How former CMS head, Tom Scully, privatized and destroyed Medicare

    David Dayen reports on former Center for Medicare and Medicaid Services (CMS) head, Tom Scully, privatized and destroyed Medicare for The American Prospect.

    Back in 2002, Scully, the administrator at CMS under President George W. Bush, attacked the incentives in the Medicare program. At the time, he was focused on hospital incentives to inflate patient costs, saying “People follow the money, and they’ll find the little niches in the program and they’ll game it, and that’s what happened here.”

    Scully, himself, has taken advantage of these “niches” since leaving government in 2003 for private equity. Scully’s view about health care is Darwinian. People should pay out of pocket for their health care, as they do for their vegetables–survival of the fittest–with help only for the poor.

    Scully doesn’t recognize the value of Medicare negotiating prices for physicians and hospitals. Of course, that’s what has kept Medicare spending down for older Americans and people with disabilities. It’s also one key way other countries get value from their health care systems. In Scully’s view, if you get sick, you should pay for it.

    It’s thinking like Scully’s that has pretty much destroyed our health care system. Physicians and patients have suffered as private equity and big corporations have seen their profits soar. “Scully’s fear of big-government price-fixers has led to the triumph of big private profit-takers, at the cost of doctors, nurses, and patient care.”

    The corporate takeover of health care has also made navigating the system challenging. It’s now so complex. Choice and competition are meaningless. They have not improved quality and they have only increased costs. Unlike with airline travel, restaurants, housing or automobiles, you have virtually no idea if the health plan you choose will deny and delay your care and endanger your health. All you know is that there’s a decent chance that your insurer will not cover your care.

    Health care corporations are in business to help their investors first and foremost. And, in the health care space, they can do so pretty easily, with little accountability, by simply extracting money from the system. Scully knows this full well and helped conceive, design and implement the algorithms that now power NaviHealth–a software AI system that helps insurers to keep more of their government payments by denying or limiting home health, nursing and rehab coverage.

    Scully sold NaviHealth before it was bought by Optum, a division of UnitedHealth. He then went on to push Congress to allow for-profit PACE programs and to invest in InnovAge, which was buying up PACE programs. Soon after, CMS addressed allegations that InnovAge was denying thousands of PACE patients medically necessary services and suspended enrollment in many of InnovAge PACE programs for a time.

    As former head of the Center for Medicare and Medicaid Innovation at the Centers for Medicare and Medicaid Services, Rick Gilfillan, explains: “When you privatize social goods like health care, you end up getting the worst of both worlds. Because it’s seen as a public good, you can’t let the marketplace operate as it normally would … you get captured regulatory processes that end up facilitating the extraction of wealth by the private sector.”

    Here’s more from Just Care:

  • Live alone? How to make sure you have the supports to get the medical care you need

    Live alone? How to make sure you have the supports to get the medical care you need

    Over the years, I’ve written about the importance of having a health care buddy, someone whom you can talk to about your health, who can be another set of eyes and ears at the doctor’s office, someone who can take you to a health care appointment. If you live alone, don’t have a buddy, and need help getting to a medical appointment, Kerri Fivecoat Campbell writes for Next Avenue about what you can do.

    If you’re married, you might not have yet thought about the complications that arise when you need someone with you after a hospital discharge or a colonoscopy visit. But, it’s challenging. Our government generally doesn’t have any systems in place to help. It can take a lot of effort.

    An Uber or other hired driver won’t help because you need someone to be with you for an extended period after discharge.

    Who can you count on when you’re living alone? Lots of people are in this situation. More than one in four adults between 50 and 64  (28 percent) live alone. More than one in three over 65 (36 percent) live alone. Many of them cannot afford to pay someone and so are often forced to skip critical medical care.

    While transportation issues always have posed challenges for single people, the situation appears to be worsening. Families are increasingly spread out across the country, and there are fewer social supports in most communities.

    How to find help? 

    If you don’t have family or friends who can serve as a health care buddy, look into the PACE program. There are hundreds across the country, although many have long waitlists. They are designed to help isolated older adults age in place, providing needed community supports. That said, beware of for-profit PACE programs. 

    It could be worth learning about senior centers and other local community organizations offering services to older adults. You can contact your Area Agency on Aging or you can visit the Eldercare Locator, a government service through the US Administration on Aging, which provides information on local resources.

    You might also try contacting your local community college or religious institution. These non-profits might offer volunteer services.

    Many communities offer free transportation services and have volunteers who can provide additional support. The challenge is finding them. So plan ahead!!!!

    Here’s more from Just Care:

  • Private equity-owned hospice and home health agencies drive up Medicare spending, jeopardize quality of care

    Private equity-owned hospice and home health agencies drive up Medicare spending, jeopardize quality of care

    Jake Johnson writes for Common Dreams about a new report from the Private Equity Stakeholder Project that focuses on private equity’s “disastrous” hold on home health care and hospice care. Vulnerable older adults and people with disabilities are paying a high price, as is the Medicare program. Congress is sitting back and watching.

    Non-profit agencies once provided most home health and hospice services. Today, for-profit companies have taken over the majority of these two industries. Two in three hospices are for-profit and two in five home health care agencies are for-profit. Private equity has invested heavily in the corporations that own these agencies.

    Medicare home health care and hospice care can be good money for corporations, so long as care is limited and low-cost. So, they are likely working to get more people to take advantage of these benefits. More Medicare investment in this care would be wonderful–many people who would benefit from this coverage are unaware they are eligible for it–if the money is being spent wisely and being directed towards more people with Medicare who want and need these benefits.

    But, if private equity investment in nursing homes and PACE programs is any indication, people are getting far lower quality hospice and home health care from companies with private equity backing, and Medicare is spending more than it should for their care. Private equity ownership of nursing homes is associated with poorer care and more deaths. The home health and hospice industries are even less regulated than nursing homes.

    With private equity, profits come first. The cost to vulnerable older adults and people with disabilities receiving care from private-equity backed companies is likely high but hard to measure. In a 2021 Congressional hearing on private-equity owned nursing homes, Congressman Bill Pascrell of New Jersey asked, “How many grandmothers and grandfathers died because profits were prized above lives, with our taxpayer dollars funding this?”

    So, are any private-equity owned hospice agencies delivering quality care and not driving up Medicare spending needlessly? As with Medicare Advantage plans, we do not have good agency-specific information. The Private Equity Stakeholder Project report concludes, more generally: “Unfortunately, for-profit home healthcare and hospice companies have been linked to lower standards of care compared to their non-profit counterparts, including, but not limited to, a lower number of visits to patients by healthcare professionals (registered nurses, physicians, or nurse practitioners) in their final days in hospice, higher rates of hospitalization in home healthcare, and poorly paid—yet highly stressed—employees in both sectors.” “This is additionally troubling, because such for-profit entities serve higher percentages of people of color and those with low incomes.”

    Congress needs to start paying attention. Already a number of home health and hospice agencies have been charged with overbilling Medicare, underpaying their workers and neglecting patient care needs. For example, there are allegations that Kohlberg Kravis-owned BrightSpring, a home health care agency, put patients at risk, and other private-equity backed agencies have been charged with fraudulent billing of Medicare and Medicaid.

    In October of last year, Senator Elizabeth Warren reintroduced the Stop Wall Street Looting Act to stop private equity’s  “predatory” and “abusive” practices, but that bill is going nowhere at the moment.

    Here’s more from Just Care:

  • PACE helps older adults stay in their community

    PACE helps older adults stay in their community

    The Program of All-inclusive Care for the Elderly (PACE) is a home and community-based program designed to keep older adults who are at risk for nursing home placement living in their community.  PACE is a partnership between a local sponsoring organization, and Medicare and Medicaid health insurance programs. To become a PACE “participant,” a person must be nursing home eligible. While a person can pay privately for services, most participants have Medicare, Medicaid, or both insurance programs.

    The PACE philosophy: PACE members are called “participants” because they are encouraged to participate in their care–decision making and active care–whenever possible.  The overarching goal of the PACE Model of Care is to keep people living in the community and out of institutional care.  While an individual does not need to visit the PACE Center, which offers adult day programs with wrap around health services, it promotes socialization and addresses common problems of isolation, loneliness, and boredom.

    Who can get PACE? Programs of All-Inclusive Care for the Elderly (PACE®) serve individuals who are age 55 or older, certified by their state to need nursing home care, able to live safely in the community at the time of enrollment and live in a PACE service area.

    How does PACE work? PACE works by providing care and services in the home, the community, and at the PACE center. It is team-based care that provides everything covered by Medicare and Medicaid if authorized by your health care team.  If your health care team decided you need care and services that Medicare and Medicaid doesn’t cover, PACE may still cover them.  The team provides comprehensive coordinated care and includes the PACE participant, physician, nurse, social worker, recreational specialist, rehabilitation specialists, and transportation specialists.

    Services: Delivering all needed medical and supportive services, a PACE program is able to provide the entire continuum of care and services to older adults with chronic care needs while maintaining their independence in their home for as long as possible. Services include the following:

    • adult day health care that offers nursing; physical, occupational and speech/language therapies; recreational therapies; meals; nutritional counseling; social work and personal care;
    • medical care provided by a PACE physician familiar with the history, needs and preferences of each participant;
    • home health care and personal care;
    • all necessary prescription and over-the-counter medications;
    • medical specialties, such as audiology, dentistry, optometry, and podiatry and speech therapy;
    • respite care; and
    • hospital and nursing home care when necessary.

    See more at: http://www.npaonline.org/policy-advocacy/value-pace#services

    Find a PACE program near you: Currently, there are 144 PACE organizations in 30 states serving 58,000 people. To find out if you or a loved one is eligible, and if there is a PACE program near you, visit www.pace4you.org or www.Medicaid.gov, or call your Medicaid office.

    Beware of for-profit PACE programs: Government audits find for-profit PACE program neglects patients, delays needed care and cancels critical care.

    Learn what to do to ensure safety at home for people aging in their communities. And, see how one new program is helping older adults remain at home with assistance from a handyman, occupational therapist and nurse. For those who like technology solutions, check out how sensors can offer peace of mind to caregivers.

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    This post was originally published on March 2, 2016

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  • How a for-profit program that should provide all-inclusive care neglects its elderly patients

    How a for-profit program that should provide all-inclusive care neglects its elderly patients

    Medicare’s Program of All-inclusive Care for the Elderly or PACE has been a godsend for a small group of vulnerable patients around the country, allowing them to age in place, with medical and social supports, and avoid moving into a nursing home. But, the federal government opened up PACE, which had historically been operated by not-for-profit agencies, to for-profit companies. Eleanor Laise reports for MarketWatch on the frightening consequences of allowing for-profit entities to administer PACE.

    PACE programs care for older adults in very poor health, with multiple chronic conditions. Nearly half of them suffer from dementia, and most of them are dual-eligibles, with both Medicare and Medicaid. PACE programs are paid a flat fee to manage each participant’s care and allow them to age in their communities.

    It goes without saying that, like Medicare Advantage plans, companies can make a killing off the PACE program if they limit the costly care their participants receive. And, though the program was once only open to non-profit companies, CMS opened it to for-profit companies more than a decade ago.

    Under the administration of non-profits, the PACE program had a wonderful reputation. Now, as for-profits are taking over PACE, it’s a different story altogether.

    One patient under the care of InnovAge—a for-profit PACE program—died, allegedly needlessly. She was admitted to the hospital, severely dehydrated and with sepsis. According to the patient’s daughter, InnovAge was MIA, failing to properly monitor her mom’s condition or even discuss it with her daughter.

    The daughter described for-profit PACE as all-inclusive neglect of elderly participants, “PANE,” with financial growth and profits as their priority. The result is delayed care, difficulty getting specialty care and poor care coordination. One former employee alleged that InnovAge was “denying [patients] access to thousands of medically necessary services.”

    An internal audit in 2016 found that hundreds of participants in California were waiting long periods of time for specialty visits. There was no record of a specialty visit for one participant experiencing heavy bleeding. A month later, the patient went to the emergency room. One employee who reported these issues to a superior ended up leaving after her reports were dismissed.

    The Centers for Medicare and Medicaid Services has stepped in, seemingly doing too little too late.  It has halted enrollment in InnovAge’s Sacramento location, but why not at all locations? It’s the same poor management everywhere.

    “Auditors found instances of ordered services being cancelled, not provided, or unreasonably delayed without any clear rationale,” CMS wrote to InnovAge. How can CMS continue to pay InnovAge to care for the participants already enrolled in its PACE program when the reason for CMS ending new enrollments is failure to provide medically necessary services!

    CMS is paying InnovAge an average of $94,000 for each of its enrollees. Former CMS administrator and InnovAge board member Tom Scully takes pride in the fact participants have fewer ER visits and hospital admissions than people in traditional Medicare. We are left to wonder how many of these participants were deprived of medically necessary care when InnovAge kept them out of the ER and the hospital.

    Where’s the oversight of InnovAge and other for-profit PACE programs you might wonder? Notwithstanding oversight requirements, precious little monitoring and reporting has occurred.

    Here’s more from Just Care:

  • Coronavirus: Minimizing the health risks of isolation

    Coronavirus: Minimizing the health risks of isolation

    Paula Span reports for The New York Times on efforts to minimize the risks of isolation for older adults during this coronavirus pandemic. It’s not normal for most people to spend so much time apart from other people. For older adults, in particular, social isolation can take a huge toll.

    As the National Academies of Sciences has reported, social isolation and loneliness are large public health risks, promoting heart disease, stroke and dementia and other poor health outcomes.The National Academies found that about one in three older adults experienced social isolation before the novel coronavirus pandemic. A study published in JAMA in 2012 found that more than four in ten older adults experienced loneliness. Since the pandemic, it’s likely that a far higher proportion of older people are experiencing social isolation and loneliness.

    It’s important to stay active however makes you happy, while keeping safe. Some older adults living at home are cooking for the first time in decades. And, many older adults who are getting Meals on Wheels benefit from a regular relationship with the person delivering the food, from a distance.

    Senior centers, YMCA’s and other organizations serving older populations are offering stay-at-home activities for their older adult members. Among other things, staff reach out to older members by phone on a regular basis. For members who use the computer, some offer concerts and lectures and classes on Zoom, as well as group conference calls.

    Two PACE programs–programs that provide all-inclusive care for the elderly–are loaning tablets to their members so that they can do email and video chats.

    Unfortunately, according to Pew Research, one-third of older adults are not able to use computer technology on their own. Many also do not have internet access.

    Whatever you do, move around as much as possible during the day. Don’t sit for too long if you can avoid it. Keep active. If you have access to stairs, climb them. Physical activity benefits your mind and body.

    Here’s more from Just Care:

  • Roundup: Housing options for older adults

    Roundup: Housing options for older adults

    Where you live can play a large role in your mental and physical health. There are a range of housing options for older adults to consider, meeting a variety of needs. Here’s a round-up of some of the most notable options.

    • Aging in place—Of all the options, remaining in your home and community as you age or “aging in place” feels best to most people. There is already familiarity with the home, neighborhood and community resources. Medical and social networks are generally in place. But, can it meet your long-term care needs?
    • Cohousing—This may be the newest type of housing springing up for older adults. These housing complexes are designed for a group of people who want to create their own community, retaining their own housing unit while sharing common spaces and other facilities. With cohousing, the group might agree to share paid caregivers as well.
    • Tiny houses—These small homes, generally no more than 400 square feet, offer people who are ready to downsize significantly a way to simplify their lives and save money on maintenance. And, you can continue to live independently in the privacy of your own home. The question is what happens when you need long term services and supports.
    • Green homes—Launched in 2003, they are small intimate nursing homes, where aides have more time to spend with residents and work to accommodate their needs, be it a late breakfast or a trip to the doctor’s office. There are now 242 licensed homes in 32 states and 150 more being developed.
    • Continuing care retirement communities—CCRCs offer housing, along with a range of social services and health care services, so you can live independently and, if the need arises, with less or more assistance.
    • Assisted living facilities–Assisted living facilities offer housing and meals as well as some social, personal care and housekeeping services. Some assisted living facilities offer small homes and others offer apartments. Most offer a common dining room.

    If you decide that you want to live entirely independently, in your home or a smaller home without long-term services and supports, plan ahead for when you may need those supports. Modifying your home sooner rather than later could prevent an unneeded fall. It could also allow you to manage in your home if you have a disability. Think through what you would want to do if you cannot remain safely in your home.

    Depending upon your situation and where you live, you may be eligible for PACE, a Program of All-Inclusive Care for the Elderly in your community. PACE provides you with the long-term services and supports they may need so that you can live safely in your home.

    If you choose to move, be sure to consider the location carefully. If you will no longer be able to see your doctors, identify new doctors and schedule appointments with them before moving. Think about whether the new location is convenient for family and friends to visit. If you like walking, make sure it is a walkable community. And, contact the local area aging on aging to learn about community resources and other benefits for older adults.

    Here’s more from Just Care:

  • Don’t be seduced by Medicare Advantage bells and whistles

    Don’t be seduced by Medicare Advantage bells and whistles

    As you’re thinking about your Medicare options this Fall, don’t be seduced by new bells and whistles available from some Medicare Advantage plans. Congress is allowing these corporate health plans, which contract with the federal government to provide Medicare benefits, to spend money on health-related services that otherwise would be spent on medical services. The question is to what extent these health plans are stinting on the delivery of medical care in order to provide the bells and whistles.

    A story in Forbes by Howard Gleckman indicates that some corporate Medicare plans will offer modest new benefits, including additional home care services, adult day programs, transportation services and home-modification services. These services will be attractive to some people with Medicare. They could help people with chronic conditions who have difficulty living independently in their homes. If you need these supports, the PACE program, which works with traditional Medicare, is another option to explore.

    Traditional Medicare does not cover these non-medical services. Rather, it covers all medically reasonable and necessary medical care you need. You can see virtually any doctor or use virtually any hospital anywhere in the United States. If you have supplemental insurance, which fills virtually all coverage gaps, such as Medigap, retiree coverage or Medicaid, your out-of-pocket costs are minimal. With Medicare Advantage, your out-of-pocket costs can be as high as $6,700 a year for in-network services alone and unlimited for out-of-network care if you’re in an HMO.

    The corporate Medicare plans do not explain how they can afford to pay for the additional non-medical services they offer. They are not receiving extra money to do so. However, for the last several years, federal audits suggest that they have overcharged the government tens of billions a year for their services. Those overpayments may be one way they fund the non-medical services, though the government is trying to get that money back. They also may be charging higher copays for people who need care. There is no data on copay amounts these plans charge their members for different services.

    Federal reports also show that these corporate health plans are not reporting accurately or completely the Medicare-covered services they are delivering their members, as they are required to do by law. That should give people who consider joining these plans pause. It’s reasonable to believe that they are stinting on the delivery of the medically necessary services they are supposed to be covering.

    Given the data, it’s particularly fair to be concerned that if you join a Medicare Advantage plan, you might be denied the care or coverage your treating physicians believe you need. A report from the Office of the Inspector General reveals that these corporate health plans engage in widespread inappropriate delays and denials of care. Since the government has yet to advise people of which corporate plans to beware of, you take a gamble when you join one of them.

    Here’s more from Just Care:

  • Cohousing: Independence, companionship and community

    Cohousing: Independence, companionship and community

    Sharon Jayson of Kaiser Health News reports on cohousing, a new trend in housing for older adults that recognizes the value of social networks. Cohousing offers older adults independence, companionship and community in one housing complex. At the same time, it can bring down people’s housing costs.

    The idea behind cohousing is that a group of people, who likely do not know each other from the get-go, get to know each other and then agree to move in to a cohousing community together. They may design the housing together, collectively deciding how to structure common areas.

    Cohousing is a way of downsizing while retaining everything you need. For example, instead of each community member owning a home with a guest room, a lawnmower and a washer-dryer, the cohousing members may pool resources and own these items jointly. They effectively create their own customized neighborhood, sharing what they decide they want to share.

    Cohousing can be designed any number of ways, depending upon the community. People may live in private homes or apartments. There might be a common house for caregivers and guests. But, whatever the set up, there is a lot of shared space.

    Today, there are 168 cohousing communities. Most of them are intergenerational. Now, several of them are exclusively for older adults.

    Cohousing communities address the problem of social isolation that confronts many people who remain in their homes as they get older. Continuing care retirement communities are an alternative housing option worth considering, as are assisted living facilities. PACE is yet another option that provides all-inclusive care to people in their communities. And, for people looking for nursing home care, there’s the Eden Alternative.

    Whatever your choice, make sure to maintain a social network and stay engaged as much as possible. Too often, people have few people to talk to or otherwise engage with as they get older. And, that can lead to both mental and physical decline.

    Here’s more from Just Care:

  • New and innovative home and community-based services for older adults

    New and innovative home and community-based services for older adults

    According to a new report from the Commonwealth Fund, 12 million older adults with Medicare have mild or serious physical or cognitive impairments (PCI) but millions cannot afford home and community supports and often end up in nursing homes. More than one in three of them have incomes below twice the federal poverty level but do not qualify for Medicaid. Fortunately, there are several new and innovative home and community-based services administered by the Centers for Medicare and Medicaid Services (CMS) to help older adults remain in their homes and communities, and the report proposes some new ones.

    CMS programs that provide home and community-based care include Independence at Home, Hospital at Home, PACE–which you can read about on Just Care here—Community Aging in Place, Advancing Better Living for Elderly (CAPABLE)–which you can read more about on Just Care here–and Maximizing Independence for Persons with Dementia (MIND) at home. While all these programs are relatively small and may not be available in your community, if you are looking for home and community-based care for yourself or someone you love, it’s worth seeing whether these programs can help.

    Older adults with serious physical or cognitive impairments, such as dementia, have a high likelihood of having multiple chronic conditions. Nearly two thirds of those living in the community have three or more chronic conditions. Virtually all of them have at least one chronic condition.

    Programs that offer community and home-based supports can improve the quality of life of older adults with PCI, helping them maintain their independence and keeping them out of nursing homes. So, the Commonwealth Fund is proposing two additional cost-effective options for providing home and community-based services for older adults who do not qualify for Medicaid.  These programs are designed to delay nursing home admissions, so they could save CMS substantial money.

    1. Medicare Help at Home would offer supplemental home and community-based care. People with Medicare could elect this benefit on turning 65. Older adults with PCI would be able to receive 20 hours a week of personal care services at home or the cash equivalent, $400 a week, for other care services. Older adults would contribute anywhere from 5 to 50 percent of the cost based on their income. A combination of income-related premiums, an extra monthly premium of $42 and a small payroll contribution from employees and employers of 0.4 percent would cover the cost. And, it could save Medicaid $1.6 billion over 14 years.
    2. Medicaid Community First Choice, a program that provides supports for people with incomes up to 150 percent of the federal poverty level available in nine states, could be made available to all people with Medicare with incomes up to 200 percent of the federal poverty level who are eligible for nursing home care. It would cost $16,224 per person a year. But, costs would be offset by fewer nursing home placements, which cost $80,000 per person a year.

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