October 18

Who Cares for the Care Givers? We All Do.

Nearly 44 million people in the United States, three-quarters of whom are women in their late 40s, spend at least 22 hours a week providing unpaid care to loved ones with a disability, illness, or terminal diagnosis, and one in four spend at least twice that amount. Typically, they assist with the activities of daily living such as bathing, dressing, toileting, and feeding their loved one, as well as taking care of shopping, finances, and transportation to and from medical appointments.

These responsibilities generally last at least three years, with demands increasing as the loved one nears death. Caretaking offers emotional and other personal rewards, but when added to other family and personal responsibilities, it can impact the caregivers’ employment and their own personal well-being. Depression and burnout among caregivers can often lead to poor health choices, including turning to unhealthy use of substances.

How can we support these unpaid millions who are themselves hurting? There are steps that can mitigate, or at least control, some undue stress for the caregiver.

With attention focused on the patient, it is easy to overlook the needs of the caretaker. Because of their outsized responsibilities, caregivers report a reduction in the ability to experience positive activities in their own daily lives by almost a third in comparison to non-caregivers. It is estimated that between 40 percent and 70 percent of caregivers have clinically significant symptoms of depression and up to half meet the diagnostic criteria for major depression. As the loved one’s functional status declines, levels of caregiver depression and perceived burden tend to increase. New stresses arise for those who try to locate appropriate end-of-life care for their loved ones. They may also question whether the services their loved one is receiving are of high quality and properly integrated with other health care and social services.

Sensitizing communities to the mental health risks these caregivers face and increasing understanding of the importance of mental health is a good place to start. A terrific resource to accomplish these goals is Mental Health First Aid, an eight-hour course that gives people skills to help someone who is developing a mental health problem or experiencing a mental health crisis. It was created in Australia by Betty Kitchener and Anthony Jorm, and brought to the United States by the National Council for Behavioral Health. Mental Health First Aid teaches individuals how to identify, understand, and respond to signs of mental illness and substance abuse disorders in their community.

With more than a million people trained in mental health first aid across the country by 11,800 instructors, the impact has been invaluable. Mental health first aiders include teachers, first responders, veterans, parents, friends, students, mayors, and first ladies including former First Lady Michelle Obama. First responders who have completed the training report that it has changed the way they do their jobs. They have learned to approach people differently, responding to calls equipped with the “right tools” or questions to ask and ultimately connecting individuals to the help they need. Students completing the youth mental health first aid training report they have learned to be better friends, feel more comfortable knowing what to do in difficult situations, and can now apply principles learned in their lives. This is making a difference in high schools and college campuses.

This program has improved and saved lives by increasing awareness in communities about behavioral health. Mental health first aid for older adults is a special program that addresses the unique risk factors and warning signs of mental health problems in adults older than age 65 and provides the tools to recognize them and respond.

Taking this course can help caregivers and people who know caregivers develop a better understanding of how to help an older adult who is in crisis or experiencing a mental health challenge. It also empowers the caregiver with knowledge about how to select an intervention and provide initial help. More than one million volunteers in the United States have completed the training and many report that just knowing they have the skills to assist someone experiencing a mental health crisis gives them a feeling of confidence and a heightened sense of responsibility to their community.

An essential element of mental health first aid is self-care. Just as mental health first aiders become more aware of their role in mental health within their families and communities, they are reminded that maintaining their health is key to helping others. This “care for the caregiver” aspect of mental health first aid training is critical for the population of caregivers.

In addition to sensitizing communities to be aware of mental health risks for caregivers, it is important to note that caregivers also have a higher risk of losing employment while caring for loved ones with complex care/end-of-life support needs. Helping caregivers stay employed is an important support strategy in decreasing caregiver burden. However, with limited protection under the Family Medical Leave Act, the caregiver may be forced to work fewer hours or drop out of the workforce altogether. Research illustrates that the economic toll on caregivers can be devastating. A 2013 study shows the overall unpaid value of caregiving contributions is around $470 billion—up $20 billion from 2009 and double the impact of paid caregivers and nursing homes combined. For caregivers who remain employed, lost productivity is estimated to average more than $25 billion annually, on top of a rate of about one week of absenteeism annually per caregiver.

Loss of employment can not only create financial hardship, one study found that employment had a protective effect on women caregivers who reported that work provided a buffer from the stress of caregiving. The additional income also provided them with the financial and social resources to maintain a higher level of self-care and embrace a healthier lifestyle with greater access to more fresh fruits and vegetables, medicines, and health care than their unemployed counterparts. Workplace policies that offer employees flexibility around their caregiving also have been shown to help reduce rates of depression in this group. The National Alliance for Caregiving study of Best Practices in Workplace Eldercare identifies current trends and innovations in workplace policies and practices that support employees with eldercare responsibilities including individuals with complex care needs.

Navigating the complex health system is the last thing overburdened caregivers need to deal with; understanding the protections afforded under the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 can help alleviate the burden. The MHPAEA requires group health plans and health insurance issuers to ensure that financial requirements and treatment limitations applicable to mental health or substance use disorder benefits are no more restrictive than the predominant requirements or limitations applied to substantially all medical and surgical benefits.

What this means for the caregiver is that there must be comparable copayments for mental health and substance use disorder care and physical health care. If there are no limits on the number of outpatient visits for physical care, there can be no limits for outpatient mental health or substance use disorder care, and prior authorization requirements for mental health or substance use disorder services must be comparable to those for physical health services.

We can all make a difference by increasing awareness in our own communities and sharing resources with local community organizations, caregivers, and people who may know someone who is struggling. As an example, “Know Your Rights: Parity for Mental Health and Substance Use Disorder Benefits” is a consumer-oriented brochure that provides an overview of the MHPAEA and provides resources for additional information about state and federal parity laws. It discusses which health care benefits should be covered under a patient’s health plan or insurance. These include clinical treatment, health care services, and medications.

While policy-driven programs to support the mental health of caregivers are important and should be pursued, there are interventions we can implement immediately, without waiting for legislators to act. The first step is to adopt a caring attitude for our caregivers and to educate ourselves about the simple but effective ways we, as community members, can help.

Article Courtesy of Nicole Cadovius, the director of practice improvement for the National Council for Behavioral Health

October 17

Medicare Guide 2017: Check for providers in ‘narrow networks’

Fewer than half of all doctors in Multnomah County and other U.S. metropolitan areas are covered by privately run Medicare Advantage plans, a new study has found.

The Kaiser Family Foundation, an independent health policy research center, found that more than 1 in 3 enrollees in private Medicare Advantage plans had access to “narrow networks” comprising less than 30 percent of the physicians and specialists in their areas.

The findings underscore how important it is that seniors ensure their doctors and care centers are included in their plan’s preferred network. Enrollees who go to out-of-network providers either pay more for their care or get no help from their plan.

Yet that task isn’t simple. Network sizes are not prominently advertised by insurers or the government, and provider directors can change at any time, experts say.

“Most of the provider directories are hundreds of pages, and some are organized differently,” said study co-author Gretchen Jacobson, associate health policy director at the foundation in Washington, D.C. “Even some broad network plans had relatively few physicians in specialties.”

Insurance broker Drew Shavere, president of Columbia Benefits Group in Wilsonville, recommends clients use online provider directories, which are more up-to-date than printed directories.

“It can be a little cumbersome,” he said. “The more doctors someone has, the more legwork there is. Not all carriers publish a printed directory. The insurance carriers will tell you themselves those are outdated almost as soon as they’re printed.”

Medicare Advantage plans offer beneficiaries the chance to get their coverage from private insurers and health organizations. Nationwide, 19 million — or 1 in 3 — seniors do, but in Multnomah County, nearly 60 percent enroll in such plans, one of the highest rates in the country.

The study examined nearly 400 plans in 20 U.S. counties, including 30 plans in Multnomah County. On average, the plans covered 46 percent of the providers in a county. In Multnomah County, they covered 42 percent.

None of Multnomah County’s plans offered a “broad network” covering at least 70 percent of the medical providers in the county, while 1 in 5 plans had narrow networks.

Plans most severely limited access to psychiatrists, cardiothoracic surgeons, neurosurgeons, plastic surgeons and radiation oncologists, the study found. In Multnomah County, plans covered only 29 percent of geriatricians, 34 percent of cancer doctors and surgeons, and 31 percent of physiatrists, who specialize in rehabilitation.

Those results were surprising, Jacobson said, because geriatricians specialize in caring for older people, and physiatrists often help seniors rehabilitate from surgeries, arthritis or broken bones.

The study’s authors suggested that insurers limit access to providers to control costs and quality of care.

The foundation, which isn’t affiliated with Kaiser Permanente, believes the study to be the first of its kind to assess the size and makeup of physician networks in Medicare Advantage plans. Experts say networks have been contracting in recent years, but the study only looked at network sizes in 2015.

Article Courtesy of Brent Hunsberger of The Oregonian

October 16

Social Security Announces 2.0 Percent Benefit Increase for 2018

Monthly Social Security and Supplemental Security Income (SSI) benefits for more than 66 million Americans will increase 2.0 percent in 2018, the Social Security Administration announced today.

The 2.0 percent cost-of-living adjustment (COLA) will begin with benefits payable to more than 61 million Social Security beneficiaries in January 2018. Increased payments to more than 8 million SSI beneficiaries will begin on December 29, 2017. (Note: some people receive both Social Security and SSI benefits) The Social Security Act ties the annual COLA to the increase in the Consumer Price Index as determined by the Department of Labor’s Bureau of Labor Statistics.

Some other adjustments that take effect in January of each year are based on the increase in average wages. Based on that increase, the maximum amount of earnings subject to the Social Security tax (taxable maximum) will increase to $128,700 from $127,200. Of the estimated 175 million workers who will pay Social Security taxes in 2018, about 12 million will pay more because of the increase in the taxable maximum.

Information about Medicare changes for 2018, when announced, will be available at www.medicare.gov.

The Social Security Act provides for how the COLA is calculated. To read more, please visit www.socialsecurity.gov/cola.

October 13

Congress Approves NOTICE Act (Observation Status)

The U.S. Senate unanimously approved legislation Monday night requiring hospitals across the nation to tell Medicare patients when they receive observation care, but have not been admitted to the hospital. It’s a distinction that’s easy to miss until patients are hit with big medical bills after a short stay. The vote follows overwhelming approval in the U. S. House of Representatives in March. The legislation is expected to be signed into law by President Barack Obama, said its House sponsor, Texas Democratic Rep. Lloyd Doggett. It’s called the NOTICE Act, short for “Notice of Observation Treatment and Implication for Care Eligibility.” The law would require hospitals to provide written notification to patients 24 hours after receiving observation care, explaining that they have not been admitted to the hospital, the reasons why, and the potential financial implications. Meanwhile, the number of claims hospitals submitted for observation care continues to skyrocket. According to the most recently available data from CMS, total claims increased 91 percent since 2006, to 1.9 million in 2013. Long observation stays, lasting 48 hours or more, rose by 450 percent to 170,219 during the same period, according to a Kaiser Health News analysis. In 2013, Medicare officials attempted to control the use of observation care by issuing the so-called “two-midnight rule,” which would require hospitals to admit patients who doctors expect to stay at least two midnights. But Congress delayed its enforcement after hospitals said the rule was confusing and arbitrary.

For the complete story Click Here

October 12

Centers for Medicare and Medicaid Services (CMS) Proposes New Regulation to Govern Nursing Home Arbitration Agreements

On July 16, 2015, CMS published in the Federal Register an exhaustive proposed rule on requirements for long-term care facilities. One of the proposed provisions concerns dispute resolution — specifically, binding arbitration agreements — at Sec. 483.70(n). The posted background on this topic provides, “We considered not proposing any requirements concerning binding arbitration agreements. We share stakeholders’ concern that some nursing homes may be requiring residents to sign agreements for binding arbitration as a requirement for admission into the facility. In addition, if the nursing home is not requiring the agreement as a condition of admission, some facilities may be requesting the resident to sign the agreement without fully explaining the rights the resident is waiving and the consequences of that waiver. We have proposed specific requirements if a nursing home chooses to request that a resident sign an agreement for binding arbitration. These requirements include, among other things, that the nursing home must explain the agreement to the resident in a form and manner that he or she understands, and that the resident acknowledge that they understand the agreement. We have also proposed specific requirements for the agreement, including that admission to the facility cannot be contingent upon the resident signing the agreement, the agreement must be entered into voluntarily, and the arbitration must be conducted by a neutral arbitrator in a venue convenient to both parties.

For full text of the proposed legislation Click Here

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