By Jake Harper via NPR.org

Kentucky got the green light from the federal government Friday to require people who get Medicaid to work. It’s a big change from the Obama administration, which rejected overtures from states that wanted to add a work requirement.

Medicaid’s chief federal officer is Seema Verma; her home state of Indiana submitted plans for a work requirement last year, and the approval letter could come any day now. Under the proposal, people would have to average 20 hours a week of work or another qualifying activity — such as volunteering or getting an education — to get Medicaid.

The goal is to increase employment among Medicaid recipients. But Sara Rosenbaum, a professor of health law and policy at George Washington University, says there’s a problem with that — most people on Medicaid are already working, or looking for work. Or they’re caring for a child or family member, or they’re sick or disabled.

Many of those people would be exempt from a work requirement, and states could also make some allowances for people battling addiction. When you consider all those exemptions, says Rosenbaum, “There is this very, very tiny slice of [of the population] who can work and simply choose not to work and apply for public assistance.”

And even if states create programs that help people find jobs, and provide things like childcare and transportation, Rosenbaum says, there’s no evidence that they would lead to more employment. And those programs are expensive.

“If you do a work program, it costs real money,” she says, “and the federal government has said, ‘we won’t pay any of those costs.’ “

What’s more likely, Rosenbaum says, is that states will basically say, ‘Get a job on your own, or get off Medicaid.’ “

And what that does, she says, is create a hurdle for everybody on Medicaid. People who are working are going to have to prove they are employed, so even people with jobs could stand to lose their insurance because of red tape. In fact, the state of Indiana’s own projections show that with a work requirement, Medicaid will cover fewer people and cost more.

Adam Mueller is an attorney at Indiana Legal Services, which helps people navigate that state’s Medicaid program. He says people already lose coverage because the program can be confusing, and there are administrative errors.

“Somewhere along the way, paperwork gets lost; there’s a miscommunication,” he says, “Folks have sometimes had difficulty proving something as easy as residency.”

And people on Medicaid often deal with crises – they may move a lot, or change phone numbers, which makes it hard to keep track of paperwork. Adding a work requirement on top of all that, Mueller says, would make staying enrolled even harder.

“There are a lot of things that can trip folks up, and that could lead to falling through the cracks,” he says.

Judith Solomon, of the Center for Budget and Policy Priorities, points out that expanded Medicaid helps some employers, too.

“We have an economic structure where there are people whose employment doesn’t provide health care,” she says.

If employees lose Medicaid, get sick and can’t make it to work, she says that’s bad for business.

Verma told reporters during a conference call Thursday that the requirement is supposed to help people.

“People moving off of Medicaid is a good outcome,” she said, “because we hope that that means they do not need the program anymore, that they have transitioned to a job that provides health insurance or that they can afford insurance on their own. This policy helps people achieve the American dream.”

But advocates say the main purpose of Medicaid is to provide health insurance, not increase employment. And until now, the federal government agreed.

Susan Jo Thomas heads Covering Kids and Families of Indiana, which advocates for health coverage in the state. Under Medicaid’s new management, she says, the philosophy surrounding work requirements has changed.

“I don’t know if it jibes with my view of Medicaid, but my view of Medicaid now is irrelevant,” she says. “It’s what Seema Verma and the administration and the folks who are at CMS decide.”

Thomas says she is taking more of a wait and see approach — the details of the work requirement have yet to be ironed out. She says if too many people lose insurance, she’ll be raising concerns with the state.

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.”