By Susan Jaffe via NPR.org

Colin Campbell needs help dressing, bathing and moving between his bed and his wheelchair. He has a feeding tube because his partially paralyzed tongue makes swallowing “almost impossible,” he says.

Campbell, 58, spends $4,000 a month on home health care services so he can continue to live in his home just outside Los Angeles. Eight years ago, he was diagnosed with amyotrophic lateral sclerosis, or Lou Gehrig’s disease, which relentlessly attacks the nerve cells in his brain and spinal cord and has no cure.

Because of his disability, he has Medicare coverage, but he can’t use it for home care — as the former computer systems manager has been told by 14 home health care providers.

That’s an incorrect but common belief. Medicare does cover home care services for patients who qualify but, according to advocates for seniors and the home care industry, incentives intended to combat fraud and reward high quality care are driving some home health agencies to avoid taking on long-term patients, such as Campbell, who have debilitating conditions that won’t get better. Rule changes that took effect this month could make the problem worse.

“We feel Medicare coverage laws are not being enforced and people are not getting the care that they need in order to stay in their homes,” says Kathleen Holt, an attorney and associate director of the Center for Medicare Advocacy, a nonprofit, nonpartisan law firm. The group is considering legal action against the government.

Federal law requires Medicare to pay indefinitely for home care — with no copayments or deductibles — if a doctor ordered it and patients can leave home only with great difficulty. They must need intermittent nursing, physical therapy or other skilled care that only a trained professional can provide. They do not need to show improvement.

Those who qualify can also receive an aide’s help with dressing, bathing and other daily activities. The combined services are limited to 35 hours a week.

Medicare affirmed this policy in 2013 when it settled a key lawsuit brought by the Center for Medicare Advocacy and Vermont Legal Aid. In that case, the government agreed that Medicare covers skilled nursing and therapy services — including those delivered at home — to maintain a patient’s abilities or to prevent or slow decline. It also agreed to inform providers, those who audit bills, and others that a patient’s improvement is not a condition for coverage.

Campbell says some home health care agencies told him Medicare would pay only for rehabilitation, “with the idea of getting you better and then leaving,” he says. They told him that Medicare would not pay them if he didn’t improve, he says. Other agencies told him Medicare simply did not cover home health care.

Medicaid, the federal-state program for low-income adults and families, also covers home health care and other home services, but Campbell doesn’t qualify for Medicaid.

Securing Medicare coverage for home health services requires persistence, says John Gillespie, whose mother has gone through five home care agencies since she was diagnosed with ALS in 2014. He successfully appealed Medicare’s decision denying coverage, and afterward Medicare paid for his mother’s visiting nurse as well as speech and physical therapy.

“You have to have a good doctor and people who will help fight for you to get the right company,” says Gillespie, of Orlando, Fla. “Do not take no for an answer.”

Yet a Medicare official did not acknowledge any access problems. “A patient can continue to receive Medicare home health services as long as he/she remains eligible for the benefit,” says spokesman Johnathan Monroe.

A leading industry group contends that Medicare’s home health care policies are often misconstrued. “One of the myths in Medicare is that chronically ill individuals are not qualified for coverage,” says William Dombi, president of the National Association for Home Care and Hospice, which represents nearly half of the nation’s 12,000 home care providers.

Part of the problem is that some agencies fear they won’t be paid if they take on patients who need their services for a long time, Dombi says. Such cases can attract the attention of Medicare auditors who can deny payments if they believe the patient is not eligible, or they suspect billing fraud. Rather than risk not getting paid, some home health agencies “stay under the radar” by taking on fewer Medicare patients who need long-term care, Dombi says.

And those companies may have a good reason to be concerned. Medicare officials have found that about a third of the agency’s payments to home health firms in the fiscal year ending last September were improper.

Shortages of home health aides in some areas might also lead an overburdened agency to focus on those who need care for only a short time, Dombi says.

Another factor that may have a negative effect on chronically ill patients is Medicare’s Home Health Compare ratings website. It includes grades on patient improvement, such as whether a client got better at walking with an agency’s help. That effectively tells agencies who want top ratings “to go to patients who are susceptible to improvement,” Dombi says.

This year, some home care agencies will earn more than just ratings. Under a Medicare pilot program, home health firms in nine states will start receiving payment bonuses for providing good care and those who don’t will pay penalties. Some criteria used to measure performance depend on patient improvement, Holt says.

Another new rule, which took effect last Saturday, prohibits agencies from discontinuing services for Medicare and Medicaid patients without a doctor’s order. But that, too, could backfire.

“This is good,” Holt says. “But our concern is that some agencies might hesitate to take patients if they don’t think they can easily discharge them.”

By Brian Scudamore via Forbes.com

When you think of a typical entrepreneur, Mike Sandness isn’t the first image that comes to mind. He’s a greying, 50-something, Air Force vet who spent 20 years at the same corporate job. Life was comfortable and, like many people his age, he had started planning for retirement. Then he was laid off.

As he struggled to figure out what to do next, Mike stumbled across our brands. He realized getting laid off could be an opportunity to have a second career doing something he’d always dreamed of. He took a leap and chose entrepreneurship over retirement; now he runs a thriving WOW 1 DAY PAINTING franchise.

Mike is one of a growing population of retire-preneurs: people using their would-be retirement as a chance to be their own boss. We’ve seen this first hand at our company, as more and more of our franchise applicants fall into this older age bracket. Apparently, the face of entrepreneurship is older than we thought!

Boomers vs. Millennials: Who Makes a Better Entrepreneur?

Twenty years ago, more than a third of entrepreneurs were the same age that millennials are now. Today, three quarters are gen X or older, with 70% of soon-to-be retirees saying they want to keep working. Boomers are now more likely to start businesses than their millennial counterparts.

It makes sense: Boomers have decades of experience, which means they also have access to larger networks. They’ve had years to stockpile funds so they don’t need to worry as much about startup capital. In our franchise system alone, they’re some of the strongest business owners.

Despite these clear advantages, there’s a common misconception that “entrepreneur” is synonymous with “20-something tech genius.” But there’s no age limit on creativity, strategic thinking or leadership; entrepreneurship is a skill that transcends the confines of any given generation.

Why Not Just Retire?

Layoffs, age discrimination, corporate burnout — there’s a number of reasons people end up without a job in middle age. Although many take retirement as a natural next step, others have the drive to keep going and build something of their own. It’s a dream they’ve never had the luxury to pursue, until now.

When Boomers entered the working world, it was normal to stick to one job for life. Post-Depression, if you had a good job, you damn well kept it. Now, in their 50s and 60s (or even 70s and 80s!), they’re ready to walk away from the 9 to 5. This doesn’t mean they want to call it quits on work altogether — but they’re sick of someone else controlling their lives.

Retire-preneurs value a flexible schedule over a high-paying job. This is often the first time in their lives they can actually afford to work less, and that’s what makes entrepreneurship an appealing option. Running a business lets them set their own schedules, take the leadership seat, and it keeps their minds active. It’s less about making money; it’s about wanting to do something meaningful with their retirement.

What Do Retire-preneurs Mean for the Economy?

When Mike was laid off, he had three choices: find another corporate job, lean in to early retirement, or take a chance on himself. Like many of his fellow retire-preneurs, he thought it was too late (and too risky) to start a business in his 50s. But he also realized it was now or never — so he chose to believe in himself and leveraged his years of experience to become an entrepreneur.

The rise of the retire-preneur does more than give the aging population something to pass the time; it’s allowing them to contribute to the economy by creating a rich ecosystem of knowledge and support for entrepreneurs across the board. By using their life’s experience to lead their own businesses, this cohort is passing their wisdom on to the next generation. Their second careers are an opportunity to advise and coach business leaders of tomorrow.

The question is this: if you’re fulfilling a dream, does it really matter when you do it? Or is it about finally finding the opportunity to take the road less travelled and create a future you always envisioned?

By John Daley VIA NPR.org

The expansion of Medicaid helps rural hospitals stay afloat in states like Colorado, which added 400,000 people to the health insurance program under the Affordable Care Act.

Hospitals in states that expanded Medicaid were about 6 times less likely to close than hospitals in non-expansion states, according to a study by researchers at the University of Colorado Anschutz Medical Campus.

The study was published Monday in the January edition of the journal Health Affairs.

Colorado was one of 32 states to expand Medicaid under the Affordable Care Act. That cut the state’s uninsured rate in half. The biggest group that got coverage was childless adults.

Richard Lindrooth, a professor at the Colorado School of Public Health and lead author of the study, says hospitals saw more people showing up to hospitals with that insurance — so Medicaid payments increased. That helped the hospitals’ bottom line.

“It’s not as though Medicaid is an extremely profitable form of reimbursement, but it is something,” says Lindrooth, a professor the University of Colorado’s School of Public Health. “On the margins, it certainly helps the hospitals’ cash flow.”

Lindrooth says he and his colleagues hypothesized that hospitals in expansion states stood a better chance of remaining financially viable. So they examined national hospital data and local market conditions.

They compared four years before the Affordable Care Act went into effect (2008-2012) with years right after the launch of the ACA (2015-2016). Lindrooth says the results were noteworthy, especially for rural hospitals, which often struggle to stay open.

“Rural hospitals tend to be in more of a financially tenuous position, even prior to the Medicaid expansions,” Lindrooth says. “We found that really about half of the closures that did occur in non-expansion states could have been averted through the expansion.”

With more insured people in expansion states, hospitals made more money and provided less free care. “So overall their margins improved,” he says. Rural hospitals in non-expansion states didn’t have that advantage.

Rural health leaders said the study confirmed what they’ve seen on the ground.

Jason Cleckler, CEO of Delta Memorial Hospital in Delta, Colo., in the rural western part of the state, said the Medicaid expansion helped his hospital’s finances. He compared the numbers in 2011 with 2016, after expansion. The hospital’s Medicaid population grew from 10 percent to 20 percent, and the hospital was left with less uncompensated care. It saved the hospital more than $3 million.

“I think that really speaks to what the researchers found. So Medicaid doubled, our bad debt decreased significantly, and the uninsured rate decreased significantly,” Cleckler says. “It’s pretty remarkable, and I would venture to say that most hospitals, even ones with a lower percentage of Medicaid, have experienced a similar story.”

Cleckler did describe Medicaid coverage as a “mixed bag” for rural providers. Reimbursement rates can be paltry, he says. A hospital that pays $100 for a lab test may only be reimbursed $20. Another problem, he said, is many doctors and providers either won’t accept or limit the number of Medicaid patients due to low reimbursement rates.

An average of 30 percent to 50 percent of rural patients are covered by Medicaid, noted Michelle Mills, CEO of Colorado Rural Health Center, which offers rural health providers education and training. Mills says the population in rural areas is generally “older, sicker and poorer” than in urban communities.

She says the expansion plus a bump in Medicaid reimbursement rates “has helped rural Colorado hospitals from closing.” The jobs generated by those hospitals are key to rural economies, with health care one of the top three rural employers in Colorado.

“The importance of Medicaid expansion in our state cannot be understated,” says Cara Welch, director of communications with the Colorado Hospital Association.

Welch says other factors also provided a boost, including the state’s strong economy and its hospital provider fee. That fee helps reimburse hospitals for uncompensated care from the indigent population and those paying with Medicaid.

Brock Slabach, senior vice president of the National Rural Health Association, says the study correlates with data the group has reviewed. “If state legislatures and Congress want to cure the rural hospital closure problem, expanding Medicaid and not block-granting this important program would be the answer,” he says.

Members of the Republican majority in Congress have suggested changing Medicaid to a block grant. That means that instead of the federal and state governments sharing payment for every enrollee who qualifies, the federal government would provide each state a set amount of money, capping total Medicaid spending. It would let states decide how to spend the money. But health care and hospital advocates worry that the change would likely lead to cuts over time.

This story is part of a reporting partnership with NPR, Colorado Public Radio and Kaiser Health News.

By Mark Miller via Reuters.com

CHICAGO (Reuters) – Finding a safe, high-quality nursing home for a loved one is never an easy task. Complicated decisions often are made at a moment of emotional crisis and reliable guidance can be difficult to come by.

And it is going to get more difficult. The Trump administration is moving quickly to deregulate nursing homes, complying with a wish list submitted by industry lobbying groups. Consumer advocates worry that the changes will lead to deterioration in safety and the quality of care delivered to some of the most vulnerable Americans.

Just before the holidays, news broke that the Trump administration is curtailing the use of penalties against nursing homes that harm their residents or put them at risk of injury.

The story, first reported in the New York Times (nyti.ms/2EcObyR), is just the latest in a series of rapid-fire moves by the Centers for Medicare & Medicaid Services (CMS) to loosen, delay or strip away regulation of nursing homes.

In November, CMS exempted nursing homes that violate new patient safety rules from financial penalties for 18 months. In June, it proposed to reverse an Obama administration rule prohibiting clauses in residents’ contracts requiring them to use arbitration to settle disputes rather than go to court.

“The industry sees this administration as a real golden opportunity to get what it wants,” said Toby Edelman, senior policy attorney at the Center for Medicare Advocacy (CMA), a nonprofit group that provides Medicare-related education, advocacy and legal assistance to seniors.

CMS has broad authority to regulate nursing homes that accept patients covered by Medicare and Medicaid – virtually all nursing homes in the United States. Its recent moves will take an industry where enforcement of rules has been weak, and make it weaker still, Edelman argues.

Nursing homes subject to the Obama penalty rules generally were limited to those suspected of harming residents or placing them in immediate jeopardy. The repeal of CMS guidance in this area will leave even these nursing facilities facing looser regulation.
DOING THE HOMEWORK

Nursing home choices often are made during stressful times for families, when a patient’s hospital stay is ending and the shift to a skilled nursing facility is imminent. That leaves the door open to rapid, emotion-driven decision making. “So don’t do that,” urged Robyn Grant, director of public policy and advocacy at the National Consumer Voice for Quality Long-Term Care.

“It’s really a good idea to do a little research before a crisis emerges,” she said. “If something happened to me or a family member, where do I want to go?”

Unfortunately, information rating the quality of nursing homes is spotty. A good starting point is Medicare’s system for rating nursing homes for quality of care and staffing levels, called Nursing Home Compare (bit.ly/1CHwbuM). The system rates nursing homes on a scale of 1 to 5 and is considered the industry authority.

But much of the data that determines ratings is self-reported by nursing homes, and the ratings do not take into account negative information such as fines and enforcement actions by states. And reviews of this system have found numerous cases of facilities attempting to “game” the system.

One study published last year of California nursing homes between 2009 and 2013 found inflated star ratings. Forty percent of the facilities received four or five stars in 2009, but that had risen to 60 percent in 2013. The researchers found little correlation between the ratings and actual health inspections by state regulators.

Nursing home shoppers also should consult Nursing Home Inspect, an online database created and maintained by ProPublica, the nonprofit investigative news service (bit.ly/2mh8SCC). The database contains state-by-state breakdowns displaying fines and deficiencies turned up by inspections, and it flags nursing homes with histories of serious quality issues.

Grant recommends checking on any facility you are considering with your state’s long-term care ombudsman, a program administered by the Administration on Aging. Consumer Voice offers a directory of state ombudsmen on its website (bit.ly/1I1SgDp).

A trusted physician also can be a good resource, she said. “Ask them about experience with facilities. Ask a trusted doctor, ‘What facilities would you go into if you needed one?’”

She also recommends checking with friends who have had experience with facilities under consideration. Geriatric care managers – human service professionals who help coordinate care for the elderly and their families – also can help navigate the nursing home maze.

But consumer vigilance is an incomplete response to the rollback of regulatory protections now under way. “We’re talking about one of the most vulnerable populations in the country – many don’t have family living nearby or don’t have family members at all who can look out for them,” Grant said. And CMS data shows that 61 percent of nursing home residents in 2014 suffered from moderate or severe cognitive impairment, which means many will struggle to look out for their own interests.

“If you are concerned about the quality of care in nursing homes now, you have no idea what will happen if we take away these protections.”

By the Center for Medicare Advocacy

Once again the House of Representatives’ leadership are proposing to change Medicare into a private voucher system. Their proposals would have severe repercussions for Medicare beneficiaries and their families.[1] Sound solutions that would preserve Medicare coverage while reducing costs are still not being seriously addressed. With the President on record as recommending that we lower Medicare’s drug costs, perhaps now is the time.

The Center for Medicare Advocacy’s recommendations do not shift costs to beneficiaries or completely restructure the Medicare program. They are good for beneficiaries and for the economy. They promote choice and competition while shoring up the solvency of Medicare. Adopting these recommendations would be a responsible step towards reducing our deficit the right way.

1. Bring Down the Costs of Prescription Drugs

Extend Medicaid Drug Rebates to Low-Income Medicare Beneficiaries

Medicare should benefit from the same discounts for prescription drugs as Medicaid. Low-income dually eligible people (people eligible for both Medicare and Medicaid) comprise one-fourth of all Medicare drug users, and are among the most costly beneficiaries. Because Medicare, rather than Medicaid, covers most of their drugs and because Medicare cannot negotiate drug prices, these drugs are not eligible for the same rebates as they were, and would be, under the Medicaid program. Extending Medicaid rebates for dually eligibles and other low-income people could save more than $145 billion over ten years.[2] Extending drug rebates to all Medicare beneficiaries would yield even more savings.

Negotiate Drug Prices with Pharmaceutical Companies

The Medicare prescription drug law, passed in 2003, prohibits the Secretary of Health and Human Services from negotiating prices with pharmaceutical companies. These companies gained millions of potential customers when Medicare began covering prescription drugs, but they did not have to adjust their prices in return. Requiring the Secretary to negotiate drug prices for Medicare could help address rising prescription drug costs.[3] Taxpayers currently pay nearly 70% more for drugs in the Medicare program than through the Veteran’s Administration, which has direct negotiating power.[4] Savings realized from reducing Medicare drug costs could be used to improve benefits for beneficiaries and reduce the deficit.

Include a Drug Benefit in Traditional Medicare

Offering a drug benefit in traditional Medicare would give beneficiaries a choice they do not have now, encourage people to stay in traditional Medicare, and save money for taxpayers. It would also provide an alternative to private Part D and MA-PD plans that leave many with unexpected high out-of-pocket costs. A drug benefit in traditional Medicare would protect beneficiaries against expensive and sometimes inappropriate marketing practices. Further, traditional Medicare’s lower administrative costs could free up money for quality care, and could result in lower drug prices for beneficiaries.

2. Stop Paying Private Medicare Plans Anything More Than Traditional Medicare

Prior to the Affordable Care Act (ACA), payments to private Medicare Advantage (MA) plans averaged as much as 114% of the rate the traditional Medicare program spent on a comparable individual. The ACA attempted to rein in these overpayments and bring MA costs more in line with costs under traditional Medicare. Despite these changes, though, various factors prevent more equitable and accurate payment to MA plans, resulting in inflated and wasteful payments.[5]

Most egregious among such wasteful payments is the practice of MA “upcoding” – when an MA plan inappropriately reports an enrollee as being more sick than they actually are in order to obtain a higher risk-adjusted payment from the Medicare program. According to the Medicare Payment Advisory Commission (MedPAC), “after accounting for all coding adjustments, payments to MA plans were about 4 percent higher than Medicare payments would have been if MA enrollees had been treated in [traditional] Medicare.”[6] By some estimates, this practice wastes billions of dollars a year.[7]

These inappropriate payments occur amid a growing body of evidence that MA plans might not serve sicker beneficiaries as well as healthier people, including findings that those who are sicker tend to disenroll from MA plans at disproportionately higher rates than other enrollees and tend to rate traditional Medicare more favorably than MA plans for quality and access.[8]

Achieving more accurate MA payments will increase the solvency of the Medicare program and curb costs for taxpayers. In short, private plans should not be paid any more than traditional Medicare.

3. Lower, Don’t Raise, the Age of Medicare Eligibility

Some proposals to reduce the national deficit would increase the age of eligibility for Medicare from 65 to 67, or even higher. This would “save money” for the federal government by shifting costs to beneficiaries, employers and states. It would also eventually increase health care and Medicare costs, as older people go without insurance, go without needed care, and come into Medicare with more health care needs.[9]

In fact, a common sense approach to insurance argues for lowering the age of Medicare eligibility, thereby decreasing the needs and costs of those in the Medicare risk pool, increasing revenues paid into the program, and reducing overall Medicare costs.[10]

4. Let the Affordable Care Act Do Its Job

The Affordable Care Act includes many measures to control costs as well as models for reform that will increase the solvency of the Medicare program and lower the deficit while protecting Medicare’s guaranteed benefits. The Congressional Budget Office estimates that repealing or defunding ACA would add billions to the deficit while ignoring the real issue of rising overall health care costs, which contribute heavily to the growing national debt. ACA includes strong measures to allow CMS to combat fraud, waste, and abuse that will bring down costs, as well as a variety of pilot and demonstration projects that aim to bring better care and quality to beneficiaries. Allowing the ACA to do its job will improve care and hold down costs for taxpayers.

Conclusion

“Protecting Medicare” by shifting costs from the federal government to beneficiaries and their families – whether through a voucher program, spending caps, new co-payments, or other draconian measures – distorts Medicare’s original intent: to protect older people and their families from illness and financial ruin due to health care costs. The Center for Medicare Advocacy’s recommendations promote the fiscal welfare of Medicare and the country, and the health and economic security of older and disabled people. We can keep Medicare’s promise for current and future generations. There is a way if there is the will.