Recognizing the huge problems caused by opioid addiction in the United States, Medicare is adding a new outpatient opioid treatment benefit, paying for methadone and related treatment in certain facilities.
Under a new rule taking effect in January 2020, Medicare will now provide payment to opioid treatment programs (OTPs), also known as methadone clinics, as part of Medicare Part B. OTPs are the only locations where people addicted to opioids can receive methadone as part of their treatment.
Under the new OTP benefit, Medicare covers:
U.S. Food and Drug Administration (FDA)-approved opioid treatment medications (such as methadone)
Dispensing and administration of the treatment medications (if applicable)
Substance use counseling
Individual and group therapy
For beneficiaries who are eligible for both Medicare and Medicaid, Medicaid paid for methadone treatment. Now, once the OTP is enrolled in Medicare, Medicare will become the primary payer for these beneficiaries. Medicaid should continue to cover the service during the transition. Medicare Advantage plans should also allow coverage of OTPs that are not in their network while they assist beneficiaries in transitioning to an in-network OTP.
For a fact sheet from Justice in Aging, click here.
Medicaid law provides special protections for the spouses of Medicaid applicants to make sure he spouses have the minimum support needed to continue to live in the community while their husband or wife is receiving long-term care benefits, usually in a nursing home.
The so-called “spousal protections” work this way: if the Medicaid applicant is married, the countable assets of both the community spouse and the institutionalized spouse are totaled as of the date of “institutionalization,” the day on which the ill spouse enters either a hospital or a long-term care facility in which he or she then stays for at least 30 days. (This is sometimes called the “snapshot” date because Medicaid is taking a picture of the couple’s assets as of this date.)
In order to be eligible for Medicaid benefits a nursing home resident may have no more than $2,000 in assets (an amount may be somewhat higher in some states). In general, the community spouse may keep one-half of the couple’s total “countable” assets up to a maximum of $128,640 (in 2020). Called the “community spouse resource allowance,” this is the most that a state may allow a community spouse to retain without a hearing or a court order. The least that a state may allow a community spouse to retain is $25,728 (in 2020).
Example: If a couple has $100,000 in countable assets on the date the applicant enters a nursing home, he or she will be eligible for Medicaid once the couple’s assets have been reduced to a combined figure of $52,000 — $2,000 for the applicant and $50,000 for the community spouse.
Some states, however, are more generous toward the community spouse. In these states, the community spouse may keep up to $128,640 (in 2020), regardless of whether or not this represents half the couple’s assets. For example, if the couple had $100,000 in countable assets on the “snapshot” date, the community spouse could keep the entire amount, instead of being limited to half.
The income of the community spouse is not counted in determining the Medicaid applicant’s eligibility. Only income in the applicant’s name is counted. Thus, even if the community spouse is still working and earning, say, $5,000 a month, she will not have to contribute to the cost of caring for her spouse in a nursing home if he is covered by Medicaid. In some states, however, if the community spouse’s income exceeds certain levels, he or she does have to make a monetary contribution towards the cost of the institutionalized spouse’s care. The community spouse’s income is not considered in determining eligibility, but there is a subsequent contribution requirement.
But what if most of the couple’s income is in the name of the institutionalized spouse and the community spouse’s income is not enough to live on? In such cases, the community spouse is entitled to some or all of the monthly income of the institutionalized spouse. How much the community spouse is entitled to depends on what the Medicaid agency determines to be a minimum income level for the community spouse. This figure, known as the minimum monthly maintenance needs allowance or MMMNA, is calculated for each community spouse according to a complicated formula based on his or her housing costs. The MMMNA may range from a low of $2,113.75 to a high of $3,216 a month (in 2020). If the community spouse’s own income falls below his or her MMMNA, the shortfall is made up from the nursing home spouse’s income.
Example: Joe Smith and his wife Sally Brown have a joint income of $3,000 a month, $1,700 of which is in Mr. Smith’s name and $700 is in Ms. Brown’s name. Mr. Smith enters a nursing home and applies for Medicaid. The Medicaid agency determines that Ms. Brown’s MMMNA is $2,200 (based on her housing costs). Since Ms. Brown’s own income is only $700 a month, the Medicaid agency allocates $1,500 of Mr. Smith’s income to her support. Since Mr. Smith also may keep a $60-a-month personal needs allowance, his obligation to pay the nursing home is only $140 a month ($1,700 – $1,500 – $60 = $140).
In exceptional circumstances, community spouses may seek an increase in their MMMNAs either by appealing to the state Medicaid agency or by obtaining a court order of spousal support.
Contact your attorney to find out what you can do to make sure your spouse has enough income to live on.
SAN DIEGO (AP) — A company that claims to have the first drug to slow mental decline from Alzheimer’s disease made its case to scientists Thursday but left them sharply divided over whether there’s enough evidence of effectiveness for the medicine to warrant federal approval.
Excitement and skepticism have surrounded aducanumab since its developers stopped two studies earlier this year because it didn’t seem to be working, then did a stunning about-face in October and said new results suggest it was effective at a high dose.
During Thursday’s presentation at an Alzheimer’s conference in San Diego, the developers convinced some experts that the drug deserves serious consideration. But others were dubious.
Changes made during the study and unusual analyses of the data made the results hard to interpret. And the newly released results showed the drug made only a very small difference in thinking skills in one study and none in the other.
Alzheimer’s patients and families are desperate for any help, no matter how small, adding pressure on the Food and Drug Administration to approve something.
But with conflicting results, “I don’t see how you can conclude anything other than that another trial needs to be done,” said the Mayo Clinic’s Dr. David Knopman, who was involved in one of the studies.
Laurie Ryan, a dementia scientist at the National Institute on Aging, agreed: “We need more evidence.”
Other doctors who consult for the drug’s developers cheered the results. Dr. Paul Aisen, a dementia specialist at the University of Southern California, said they were “consistent and positive” in showing a benefit at a high dose — “a truly major advance.”
Aducanumab aims to help the body clear harmful plaques, or protein clumps, from the brain. Cambridge, Massachusetts-based Biogen is developing it with Japan’s Eisai Co.
In afternoon trading, the companies’ stocks were up roughly 4%.
The stakes are high for approval or denial.
More than 5 million people in the U.S. and millions more worldwide have Alzheimer’s. Current drugs only temporarily ease symptoms and do not slow the loss of memory and thinking skills.
But approving a drug that isn’t truly effective could expose patients to financial and medical risks and give other drugmakers less incentive to develop better treatments.
The makers of aducanumab undertook two studies, each enrolling about 1,650 people with mild cognitive impairment or mild dementia from Alzheimer’s.
Those with a gene that raises their risk of the disease were started on a lower dose because they are more likely to suffer inflammation in the brain from medicines that target plaque.
But as the studies went on and concern about this side effect eased, the rules were changed to let such patients get a higher dose.
A Biogen vice president, Samantha Budd Haeberlein, said more people got the higher dose in one study, and that helps explain why it succeeded and the other one failed.
But the new analyses were done on partial results, and with methods not agreed upon at the outset, which makes any conclusions unreliable, independent experts said.
Also, the drug’s benefits may have looked more impressive than they really were because patients in the placebo group worsened more in the positive study than in the one that failed.
“It’s hard to know exactly what happened here,” said Dr. Howard Fillit, chief science officer of the Alzheimer’s Drug Discovery Foundation. “I don’t see how the FDA could approve it.”
Questions also arose about the size of any benefit.
The drug did not reverse decline, only slowed the rate of it compared to the placebo group by 22% in one study. Yet that meant a difference of only 0.39 on an 18-point score of thinking skills.
“It’s a very small amount,” Fillit said.
Still, Maria Carrillo, chief science officer at the Alzheimer’s Association, said it was “the largest reduction that we’ve seen to date,” adding: “It may mean that they remember their loved ones a little longer.”
The drug “is worthy of significant, rigorous exploration” and review by the FDA, she said. “This is an important moment for the Alzheimer’s community.”
Some doctors and patients who helped test the drug are convinced it helped.
One was Charles Flagg, 78, a retired minister from Jamestown, Rhode Island, who received aducanumab until the studies were halted in March. Since he was taken off the medicine, “his cognition, his alertness, his interactions have definitely diminished,” said his wife, Cynthia Flagg.
Biogen stressed the need for an effective treatment and suggested that delaying access to a drug that may work could deprive many people of help while further study is done.
Dr. John Ioannidis, a Stanford University expert on research methods, said patients’ need should not drive the FDA’s decision.
“If we go down that path, we’re likely to introduce a lot of ineffective treatments for diseases that are really common,” he said. “It would be a complete mess.”
The Braille and Talking Book Program offers Veterans who have difficulty with regular print materials the return of the gift of reading.
Whether escaping into a great novel or staying current with popular magazines, the freedom and independence of reading are only a few steps away. This program, from the National Library Service (NLS) and the Library of Congress, provides talking books, audio magazines, and digital talking-book players free of charge.
Any honorably discharged Veteran who is blind, has low vision, or a disability preventing the reading of traditional materials is eligible. Participants choose whether their selected reading materials are delivered by mail, downloaded from the web-based service BARD (Braille and Audio Reading Download) or through the BARD mobile app for smartphones and tablets. NLS maintains a vast catalog of titles and publications from the latest best-sellers to timeless classics. Plus, Veterans have preferential status in the lending of materials and equipment.
The Braille and Talking Books Program is accomplished through a nationwide network of libraries to serve citizens and Veterans living inside the U.S. or abroad. Applying for this service is easy. Call the National Library Service at 1-888-NLS-READ (1-888-657-7323) or visit them on the web at www.loc.gov/ThatAllMayRead
Veterans served to protect freedom. Now let National Library Service provide the freedom for all to read.
Research finds that that data used by a popular website for researching the safety of nursing homes may be highly inaccurate
UNIVERSITY OF CHICAGO
The website Nursing Home Compare, sponsored by the Centers for Medicare & Medicaid Services, is a go-to resource for many families researching nursing home options for their loved ones. The number of falls that lead to injury are a critical category of concern for nursing home residents, however, a University of Chicago researcher has found that the data used by Nursing Home Compare to report patient safety related to falls may be highly inaccurate.
Prachi Sanghavi, PhD, an assistant professor in public health sciences at UChicago, uncovered significant discrepancies between the falls calculations used for Nursing Home Compare’s ratings and actual Medicare claims for falls by nursing home residents from 2011-2015. She found that only 57.5% of falls were accounted for in the Nursing Home Compare’s Minimum Data Set (MDS), which is self-reported by nursing homes. Reporting rates were higher for white residents (59%) than non-white residents (46%) and for long-term stays (62.9%) than short-term stays (47.1%). The findings were published December 29, 2019 in the journal Health Services Research.
“This is a substantial amount of underreporting and is deeply concerning because without good measurement, we cannot identify nursing homes that may be less safe and in need of improvement,” Sanghavi said.
A significant, yet preventable, risk
Falls are a leading cause of death among the over-65 population, and they can lead to other serious injuries. Patients become fearful of walking again for fear of reinjury, yet falls are considered widely preventable. They are a discrete event that is easy to identify and record, compared to other clinical conditions on Nursing Home Compare such as pressure ulcers or infections, so there should be a wealth of reliable data.
“That’s why falls are a patient safety measure on Nursing Home Compare,” Sanghavi said. “They reflect how well a nursing home does at preventing these injuries.”
Sanghavi started her research with a data set of nearly 88.7 million Medicare admissions claims from 2011 to 2015. She narrowed the sample set in stages, zeroing in on nursing home residents who met several criteria. First, their fall occurred during their time in the nursing home. Second, they were discharged from the nursing home to go to a hospital. Third, the patient’s Medicare claim was filed under the code for a major injury fall. Finally, they returned to the same nursing home after treatment for the fall.
“We wanted to be as conservative as possible in our calculations so there would be little argument about whether a fall should have been reported,” Sanghavi said. “Our primary outcome measure was based on whether a fall with the appropriate code was reported or not.”
Using these criteria, Sanghavi identified 150,828 major injury falls in Medicare claims filed by nursing home residents. The data used by Nursing Home Compare accounted for only 57.5% of these falls, with far fewer falls being reported for black, Asian, and Hispanic patients relative to whites.
Accounting for discrepancies
Nursing Home Compare has faced prior scrutiny for using self-reported data. Sanghavi’s own research was sparked by a 2014 New York Times investigation into serious deficiencies found in nursing homes rated five stars by Nursing Home Compare.
“I found it odd that Nursing Home Compare would use self-reported data,” she said. “Having worked with Medicare claims data, I thought I could use it to study MDS reporting. The Medicare claims we used are hospital bills. They want to get paid and should not have an interest in nursing home public reporting. That’s why they are a more objective source than the self-reported data from nursing homes.”
Sanghavi has two theories on why the reporting rate is nearly 15 points higher for long-term stays than short-term stays. “It could be that the nursing homes are more familiar with long-stay patients,” she said. “Plus, the falls measure on Nursing Home Compare is specifically for long stays. It could be that nursing homes are taking that measure more seriously.”
Sanghavi was especially surprised by the 13-point difference in falls reporting between white and non-white residents. “I didn’t expect it to be that different by race,” she said, “but it is consistent with other modes of racial disparities in long-term care.”
Based on her results, Sanghavi suggests that the Centers for Medicare & Medicaid Services change their evaluation criteria for falls on Nursing Home Compare.
“They should use an objective source, like claims data,” she said. “It should be relatively easy for them to do, since they already have the data. There are other claims-based measures already used on Nursing Home Compare.”
The Social Security Inspector General (IG) recently sounded the alarm about a new scam in which thieves are emailing fake documents purporting to come from the Social Security Administration in an effort to get the victims to comply with their demands.
The Social Security Administration Office of the Inspector General (OIG) has received reports of victims who received emails with attached letters and reports that appeared to be from Social Security or Social Security OIG.
The letters may use official letterhead and government “jargon” to convince victims they are legitimate, however, they may also contain misspellings and grammar mistakes which can be a tip off that they are fake.
The IG says that this is the latest variation on what is a widespread and long-running scam involving Social Security.
Scammers make phone calls that are either live calls or robocalls in which the caller claims to be a federal employee who says there is identity theft or another problem with one’s Social Security number, account, or benefits. The fake calls may threaten arrest or other legal action, or may offer to increase benefits, protect assets, or resolve identity theft. They often demand payment via retail gift card, cash, wire transfer, internet currency such as Bitcoin, or pre-paid debit card.
Tips for Staying Vigilant to Scams
The Social Security Administration is reminding everyone that the agency will never do any of the following:
threaten you with arrest or other legal action unless you immediately pay a fine or fee;
promise a benefit increase or other assistance in exchange for payment;
require payment by retail gift card, cash, wire transfer, internet currency, or prepaid debit card; or
send official letters or reports containing personally identifiable information via email.
If there is ever a problem with your Social Security number or record, in most cases Social Security will mail you a letter. If you do need to submit payments to Social Security, the agency will send a letter with instructions and payment options.
You should never pay a government fee or fine using retail gift cards, cash, internet currency, wire transfers, or pre-paid debit cards. Scammers ask for payment this way because it is very difficult to trace and recover.
What Should You Do?
If you receive a call or email that you believe to be suspicious that claims to be about a problem with your Social Security number or account, hang up or do not respond.
You can only make one change during the current three-month window, which makes it important to be aware of any potential snags or restrictions you may encounter.
Of Medicare’s 61 million or so beneficiaries, roughly 38% (23 million) choose to get their coverage through an Advantage Plan.
Separately, if you missed your initial Medicare enrollment period and don’t qualify for an exclusion, you can sign up through March 31.
If your 2020 Medicare coverage includes an Advantage Plan that’s not a great match, you might be able to part ways with it.
During an enrollment window that opened Jan. 1 and closes March 31, you can swap your plan for another or drop it and return to basic Medicare (Part A hospital coverage and Part B outpatient coverage). Yet, before you make a change, be sure you’re aware of potential snags and any restrictions involved.
“Do your due diligence before you switch, because if you make another mistake in your choice, you’ll be stuck with it for the rest of the year,” said Danielle Roberts, co-founder of insurance firm Boomer Benefits in Fort Worth, Texas.
Also possible through March 31: If you missed your initial Medicare enrollment period and don’t qualify for an exception, you can sign up now. If this is your situation, coverage won’t start until July 1, said Elizabeth Gavino, founder of Lewin & Gavino in New York and an independent broker and general agent for Medicare plans.
Of Medicare’s 61 million or so beneficiaries, more than a third choose to go with an Advantage Plan, which delivers Parts A and B and usually Part D prescription drug coverage, along with extras such as dental and vision. While most recipients tend not to change their plan, experts generally agree that evaluating whether there’s a more cost-effective option should be a yearly process.
The current three-month opportunity to change or drop your Advantage Plan comes just a few weeks after the close of Medicare’s annual fall open enrollment, when a variety of options were available for those who wanted to make changes to their coverage.
For this current period, however, there are restrictions.
For starters, you can only switch once. This means that once you move to a different Advantage Plan or drop it for basic Medicare, the change is locked in for 2020 (unless you meet an exclusion that qualifies you for a special enrollment period).
Additionally, this three-month window does not allow you to switch from one stand-alone Part D prescription drug plan to another.
If you picked a Part D plan in the fall open enrollment period based on faulty or misleading information, you can call 1-800-Medicare at any point during the year to see if your situation would allow you to make a change.
Meanwhile, dropping an Advantage Plan in favor of basic Medicare typically means losing prescription drug coverage — which means you would have to enroll in a stand-alone Part D plan. This matters, because if you go 63 days without the coverage, you could face a lifelong penalty that gets tacked on to your premiums.
Also, if you switch back to original Medicare and want to get a supplemental policy (also called Medigap), you may not get guaranteed coverage, depending on various factors that include where you live and exactly how long you’ve had your Advantage Plan. These policies either fully or partially cover cost-sharing of some aspects of parts A and B, including deductibles, copays and coinsurance.
“You might have to go through medical underwriting and answer health questions from the insurer and you might not get coverage,” said Gavino, of Lewin & Gavino.
If you’ll be subject to a health check, be sure to apply for the supplement before you drop your Advantage Plan.
“The worst-case scenario is that you go back to original Medicare and then no company takes you for Medigap, and you’re stuck for the rest of the year,” said Roberts, of Boomer Benefits. “So the order of events is really important.”
If you want to switch to a different Advantage Plan, your options largely depend on where you live.
The average Medicare beneficiary has 28 plans available to them this year, up from 24 in 2019, according to the Kaiser Family Foundation. However, 77 counties — generally in rural areas — have no Advantage Plan available.
If you want to switch to a different Advantage Plan, remember to make sure your doctors and other providers are in-network, Roberts said. And, assuming the plan includes Part D prescription drug coverage (most do), be sure that any medications you take are covered.
One 50-year-old has the nimble metabolism of a teenager, while another’s is so creaky he developed type 2 diabetes — though his immune system is that of a man 25 years his junior. Or one 70-year-old has the immune system of a Gen Xer while another’s is so decrepit she can’t gin up an antibody response to flu vaccines — but her high-performing liver clears out alcohol so fast she can sip Negronis all night without getting tipsy.
Anyone over 30 knows that aging afflicts different body parts to different degrees. Yet most molecular theories of aging — telomere shortening, epigenome dysregulation, senescence-associated secreted proteins, take your pick — don’t distinguish among physiological systems and organs, instead viewing aging as systemic.
Nonsense, say scientists at Stanford University School of Medicine. In a study published on Monday in Nature Medicine, they conclude that just as people have an individual genotype, so too do they have an “ageotype,” a combination of molecular and other changes that are specific to one physiological system. These changes can be measured when the individual is healthy and relatively young, the researchers report, perhaps helping physicians to pinpoint the most important thing to target to extend healthy life.
“This really presents a new framework to think about aging,” said epidemiologist Norrina Bai Allen of Northwestern University’s Feinberg School of Medicine, an expert in the biology of aging who was not involved in the Stanford study. “It’s an important first step toward showing how different parts of a body in different people can age at different rates.”
Call it personalized medicine for aging. “Individuals are aging at different rates as well as potentially through different biological mechanisms,” or ageotypes, the Stanford scientists wrote.
“Of course the whole body ages,” said biologist Michael Snyder, who led the study. “But in a given individual, some systems age faster or slower than others. One person is a cardio-ager, another is a metabolic ager, another is an immune ager,” as shown by changes over time in nearly 100 key molecules that play a role in those systems. “There is quite a bit of difference in how individuals experience aging on a molecular level.”
Crucially, the molecular markers of aging do not necessarily cause clinical symptoms. The study’s “immune” agers had no immune dysfunction; “liver agers” did not have liver disease. Everyone was basically healthy.
If aging is truly personal, understanding an individual’s ageotype could lead to individualized, targeted intervention. “We think [ageotypes] can show what’s going off track the most so you can focus on that if you want to affect your aging,” Snyder said.
Cardio-agers, for instance, might benefit from tight cholesterol control, periodic ECGs, and screening for atrial fibrillation. Immune agers might benefit from diets and exercise to reduce inflammation.
Then again, they might not. The study did not follow people long enough to tell whether their aging biomarkers did them any harm, or were even harbingers of harm, let alone killed them, Feinberg’s Allen pointed out. “There needs to be a lot more work, and replication of the results,” before they can be the basis for anti-aging interventions, she said.
The short follow-up and small sample size — 106 people — gave other experts pause. One said he “will not comment on it in any way” and declined to elaborate.
One concern revolved around what might otherwise be the study’s strength: the dizzying number of measurements the scientists made on their volunteers, ages 29 to 75, over two to four years. Through blood and saliva and urine tests, genetic analyses, microbiome inspections of their nose and gut, and more, the scientists measured 10,343 genes, 306 blood proteins, 722 metabolites, and 6,909 microbes, among other things, and found they clustered into four ageotypes: liver, kidney, metabolic, and immune.
Different people had different “personal aging molecules” and “distinct aging pathways,” Snyder said. But just as every dish on a menu is unique but can be grouped into “meat” or “fish” or “vegan” or other category, so the molecules fell into the liver, kidney, metabolic, or immune ageotypes. (There is probably a cardio-ageotype and a neuro-ageotype, too, Snyder said, but they didn’t have enough data to characterize those.)
“That we don’t all age identically is well-established,” said biologist Judy Campisi of the Buck Institute for Research on Aging, who has helped develop an “atlas” of aging biomarkers. But the new study “furthers our understanding of why.”
All told, the study generated 18 million data points. While that sounds impressive, it raises the risk that some markers seem to be part of one or another ageotype just by chance.
But Snyder said he is “quite confident” the biomarkers are not statistical artifacts. For one thing, the researchers initially found 184 of them. But using stricter statistics, they narrowed that to 87.
One surprise was that some measurements that increased with age when the participants were averaged decreased in some individuals, while some that fell with age in most people rose in a few. For instance, hemoglobin A1C (a marker of how well cells metabolize glucose) usually rises, and so is part of the metabolic ageotype. But in dozens of people it fell — another hint that different systems age at different rates in different people.
In many of those opposites, the reason might be healthy lifestyle changes. People whose A1C fell significantly, for example, either started eating a healthier diet or lost weight, both of which can improve glucose metabolism. “Lifestyle changes, and perhaps medications, can improve some markers of aging and alter an individual’s aging pattern,” said Snyder (who is 64 and has a metabolic ageotype). In fact, 15 people got biologically younger during the study.
That healthy habits can increase both lifespan and healthspan is not exactly news. But the ageotype approach might let people target their dominant aging pathway.
“The hope is that once you identify the main cause of an individual’s aging, it opens the door to interventions — exercise or diet or intermittent fasting or medications,” said Campisi. “Ideally, a 50-year-old could get a blood test and learn that his kidney is 60 but his heart is 40, and do something about [kidney aging]. This is a step in that direction.”
BISHOP, Calif. — When Jamie Moore arrived home on a Thursday evening in March, she was surprised to find her mother-in-law in her living room. Glenda Moore, 67, had been sitting in her wheelchair for hours. Without anyone to help her to the bathroom, she’d had an accident. She was also having trouble breathing. “It was awful,” Jamie Moore recalled.
Glenda Moore told Jamie that she had been discharged from the Bishop Care Center nursing home, in Bishop, California. She had been living at the nursing home — a sprawling brick building on the side of a state highway — for several weeks, recovering from a back surgery that unexpectedly left her unable to walk much or take care of herself.
Several days earlier, nursing home administrators had shown Glenda Moore a letter from Medicare, explaining that her rehabilitation coverage was ending. She was unable to pay the nursing home’s more-than-$7,000 monthly fee, so, thinking she had no other options, she left. (A relative dropped her off at Jamie’s home, where Glenda Moore had lived previously, without telling Jamie.)
“They pushed her out and she was not ready,” Jamie Moore, who has worked as a nursing assistant, said. “She was not ready at all.”
As the family later learned, Glenda Moore had the right to appeal the Medicare decision, or to apply for Medicaid — and, if she qualified (which she later did), to stay in the nursing home on Medicaid for as long as she needed nursing care. Instead, Moore’s family said, Moore became one of thousands of Americans discharged against their wishes or evicted from nursing homes each year. (The Bishop Care Center maintains that Moore’s health had improved and that she voluntarily left the facility, and points out that they gave her a document noting her right to appeal the Medicare decision.)
Nationally, long-term care ombudsmen, who advocate for elderly and disabled residents of nursing homes and assisted living facilities, received 10,610 complaints about discharges and transfers in 2017, up from 9,192 in 2015. The ombudsmen, whose work is federally mandated and state-funded, receive more complaints about discharges and transfers than any other grievance.
The complaints likely expose just a small fraction of the problem, said Kelly Bagby, vice president at the AARP Foundation, a nonprofit that serves vulnerable people over 50.
“Most people don’t even know they have rights,” she said. And many complaints never result in a formal state investigation.
Advocates, experts and the federal government say that nursing homes tend to evict low-income, longer-term residents who receive Medicaid, to make room for shorter-term rehabilitation patients who are covered by Medicare. Medicare reimburses nursing homes at a higher rate than Medicaid, so it’s more lucrative for facilities to house Medicare patients who stay for short stints before recovering and moving elsewhere.
In California, for example, the average state Medicaid reimbursement for a nursing home is $219 per day, according to the California Association of Health Facilities, while Medicare may reimburse more than $1,000 per day, but only for up to 20 days, when patients must begin paying part of the fees. (Medicare coverage ends completely after 100 days.) Advocates say that eviction notices are often handed out around the 20-day mark.
“It is illegal to discriminate against residents based on payment source, but it happens all the time,” said Tony Chicotel, attorney at the California Advocates for Nursing Home Reform, a nonprofit that supports long-term care residents in the state. “It feels like there’s just a tidal wave of cases.”
Chicotel said he receives calls every day from panicked residents or family members being threatened with discharge from a long-term care facility.
Deborah Pacyna, director of public affairs at the California Association of Health Facilities, a trade association representing nursing homes, told NBC News that improper and illegal discharges are “a really rare thing,” and that the issue is exaggerated by media attention.
She added that California’s Medicaid program, Medical, does not provide “adequate funding” to care for many patients with complicated health issues and behavioral disorders. “Medicare pays more. Those people are rehab patients; they’re in and out,” she said. “That is how they break even,” she added of nursing homes. “Society’s problems are manifesting themselves on the doorsteps of nursing homes.”
‘You’re just a piece of garbage’
Nursing homes are legally permitted to evict residents under several conditions: if a resident’s health improves sufficiently; if his presence in a facility puts others in danger; if the resident’s needs cannot be met by the facility; if he stops paying and has not applied for Medicare or Medicaid; or if the facility closes. Facilities are obligated under federal law to give 30 days’ notice, in writing, and also to work with the resident on a transition plan.
Bagby, of the AARP, said that while some residents are issued formal discharge letters with advance notice, others are asked or pressured to leave with “no due process rights, no notice.”
In one case in Los Angeles, in April 2018, Ronald Anderson said he was woken at night by the nursing home staff at the Avalon Villa Care Center and told he was being evicted. Anderson, 51 at the time, had moved into the facility over a year earlier to recover from a partial foot amputation. He said he was loaded into a van and dropped off on a sidewalk in downtown Los Angeles, which has one of the largest homeless populations in the country, according to a report from the California Department of Public Health.
Anderson, who is diabetic, was left in a wheelchair without his insulin or testing supplies — on a street cluttered with tent encampments and broken glass. The Department of Public Health report noted that he could have slipped into a coma or died.
“You’re just a piece of garbage,” Anderson said, from the Union Rescue Mission homeless shelter in Los Angeles where he now lives. “They’ll kick you right out on the curb.”
Avalon Villa Health Care, which runs the nursing home, later paid $450,000 to settle a civil complaint filed by the Los Angeles city attorney in response to Anderson’s case and other evictions of homeless residents, with the money going toward civil penalties, hiring and training Avalon Villa staff and finding temporary housing for the facility’s homeless residents. The city attorney set up an emergency hotline and invited members of the public to report cases of resident abandonment.
A lawyer for the Avalon Villa Care Center told NBC News that the facility “strongly disputes that it has inappropriately discharged any patients” and “rejects the allegations of the city attorney.”
The Rev. Andy Bales, director of the Union Rescue Mission, said “resident dumping” from nursing homes and hospitals is so common that the shelter set up a security camera outside — which Bales calls “the dump cam” — to capture evidence of it. He said he is aware of at least four instances from the last year in which people have been dropped off on nearby streets by hospitals or nursing homes — though he believes the number is higher. As a result of the security camera, he said, “They won’t dump them off in front of us anymore.”
California’s long-term care ombudsmen received 1,404 complaints about nursing home evictions in 2018, up from 1,022 in 2014. Severallawsuitsconcerning nursing home discharges have recently been filed in the state.
Molly Davies, a California long-term care ombudsman, said that in addition to receiving more complaints about evictions, “there has also been an uptick in the egregiousness of some of these cases.”
In some instances, she and other experts said, nursing homes drop residents off at a low-cost motel and pay for a night or two. “We’ve seen cases with residents who have dementia put into a van and dropped downtown onto the streets, without the ability to care for themselves,” she said.
The California Department of Public Health does not track where nursing homes discharge patients, according to a department spokesman, nor does the California long-term care ombudsman program. In some instances, however, routine state inspections and inspections following complaints uncover problems.
In a 2018 incident, described in a California Department of Health and Human Services report, a Rosemead nursing home discharged a resident to a hotel without any medical equipment and without ensuring that the hotel was “a safe environment.” The female resident still required assistance with activities such as using the toilet and bathing, and was found to lack “the capacity to make her needs known.” The nursing home received a federal “deficiency” citation.
In another case that resulted in a deficiency citation, a nursing home resident who “needed extensive assistance” to move between locations in his bedroom was discharged to a motel — and, a few days later, ended up in a hospital for emergency care.
These practices are not unique to California. In Maryland, one nursing home resident was dropped off in Baltimore, a city she had never been to, according to the state attorney general’s office. In another instance, a Washington County Sheriff’s deputy accused a nursing home of discharging a resident to a storage unit on a hot summer day.
Even when residents appeal eviction decisions through a state process and win the right to return to a nursing home, that nursing home sometimes refuses to readmit them, a group of plaintiffs told the Ninth Circuit Court of Appeals found in July. The case is still pending, but the appeals court agreed with the plaintiffs that federal law does not allow “meaningless show trials that allow nursing homes to persist in improper transfers and discharges.”
The California Department of Health Care Services, the California Department of Public Health and the federal Centers for Medicare & Medicaid Services all declined to comment, citing department policy not to comment on pending litigation.
A push for enforcement
In 2016, the Centers for Medicare & Medicaid Services strengthened regulatory requirements around nursing home discharges and transfers, specifying that residents cannot be evicted for nonpayment while they are in the process of applying for Medicaid or appealing a Medicaid denial. A year later, the agency announced an initiative to prevent illegal nursing home discharges, acknowledging that “some discharges are driven by payment concerns, such as when Medicare or private pay residents shift to Medicaid as the payment source.”
So far, the agency has approved $784,630 for a program in California that focuses on training nursing home staff on discharge regulations, a spokeswoman said in an email. The agency also provided $84,00 for a smaller project in Montana. Beyond that, the agency is not acting directly to address illegal evictions but is instead encouraging states “to propose projects that seek to address facility-initiated discharges that violate federal regulations,” the spokeswoman said by email.
Advocates for nursing home patients said more is needed. They want both federal and state agencies to do more to enforce existing rules on evictions.
“We haven’t seen any change in practice,” said Davies, the California long-term care ombudsman. “We haven’t seen a reduction in inappropriate transfers and discharges. There are certain enforcement tools that they have that they aren’t using consistently.” These tools, she said, include substantial fines.
But the federal government has made changes that reduced fines against nursing homes that harm or endanger residents. Nursing homes used to receive fines for each day a violation was observed, but after a change the Trump administration implemented in July 2017, nursing homes are now usually fined just once per retroactive violation.
Robyn Grant, director of public policy and advocacy at the National Consumer Voice for Quality Long-Term Care, an advocacy group, says this change can affect the way illegal evictions are punished. For instance, a nursing home that evicts a patient and refuses to readmit the person may be fined one time, instead of every day that the resident is denied access to a bed.
In the first 18 months following the change in guidelines, nursing homes across the country paid about $47 million less in fines for all violations compared to the previous 18-month period, said Dr. David Gifford, senior vice president of quality and regulatory affairs at the American Health Care Association, the nursing home industry’s main lobbying group.
Gifford told NBC News that the change was not about saving the industry money, but was meant to ensure consistent standards. He said the new fine structure incentivizes nursing homes to report violations and improve resident care.
‘I thought I was completely covered’
After she left the Bishop Care Center nursing home in March, Glenda Moore grew sicker. Over the following weeks, she cycled among her son and daughter-in-law’s home, several emergency rooms and another nursing home an hour away. According to her son and daughter-in-law, she was diagnosed with a bladder infection and pneumonia.
“I don’t want to be a burden on the kids,” Glenda Moore told NBC News in an interview in April. “I had retirement insurance, I had Medicare, I thought I was completely covered. That doesn’t count for anything … I had no idea.”
In May, her family appealed her discharge from the center. At a hearing conducted by the California Department of Health Care Services, the nursing home’s administrator said Glenda Moore had left willingly, according to the state’s summary report.
The state’s hearing officer ultimately found that the facility “failed to meet all of the regulatory-mandated discharge planning requirements.” However, the hearing officer ruled in favor of the nursing home, noting that Glenda Moore agreed to leave and was given paperwork notifying her of her right to appeal Medicare’s noncoverage decision.
By late July, her weight had dropped to about 80 pounds. She was hospitalized, and on Aug. 2 she died from acute renal failure and cardiopulmonary arrest.
Her family believes she wouldn’t have become so sick if she had been able to stay in the Bishop Care Center for a few weeks longer, until she was more stable.
Jamie Moore said her mother-in-law’s experience has changed the way she thinks about her own retirement.
“I never thought about it much until now. It scares the crap out of me,” she said. “The system is the system. What are you doing to do?”
Washington, DC – U.S. Representatives Linda T. Sánchez (D-CA) and Jan Schakowsky (D-IL) today introduced the Fairness in Nursing Home Arbitration Act to protect the legal rights of elderly Americans. This legislation would prohibit long-term care facilities from requiring or soliciting residents to enter into pre-dispute, mandatory, binding arbitration agreements.
Rep. Linda Sánchez – “This legislation is about putting patients and families first. The decision to transfer a parent or loved one to a long-term care facility is heart-wrenching. I still remember the day we moved my late father into a nursing home. My family and I were focused on the quality of care and range of services the facility would provide him. We were not focused on the language in the agreement that would limit his rights should something go wrong. Under this bill, families will no longer have to worry about losing their right to a day in court. I urge my colleagues to join me in protecting one of our most vulnerable groups in society, the elderly.”
Jan Schakowsky – “Every day, families bring their loved ones to nursing homes all around the country, certain that they will receive the high-quality care and comfort they need. Unfortunately, many of them unknowingly sign away their right to seek justice and are forced into an often unfair arbitration process should a nursing home resident be harmed. Whether it’s willful neglect or a simple accident, residents and their families should have the right to seek justice in front of a judge and jury, and not be locked into a conference room for forced arbitration.”
National Association of Local Long Term Care Ombudsman (NALLTCO)
National Association of Social Workers (NASW)
National Association of State Long-Term Care Ombudsman Programs (NASOP)
National Consumer Voice for Quality Long-Term Care
Service Employees International Union (SEIU)
Rep. Sánchez first introduced the Fairness in Nursing Home Arbitration Act in the 110th Congress after hearing numerous testimony during her time as Chairwoman of the House Judiciary Committee’s Subcommittee on Commercial and Administrative Law.
AARP Senior Vice President of Government Affairs Bill Sweeney – “When individuals and their families make the difficult decision to enter a nursing home, often in emergency situations, they should not be forced to sign away their legal rights through mandatory arbitration agreements. AARP supports the Fairness in Nursing Home Arbitration Act because it would prohibit these fundamentally unfair contract provisions. In the heartbreaking cases where loved ones in nursing homes are abused or injured, they should not lose access to the judicial system. We thank Representatives Sánchez and Schakowsky for their important work on this issue.”
American Association for Justice CEO Linda Lipsen – “Forced arbitration strips our nation’s most vulnerable citizens of their legal rights when a nursing home corporation’s negligence causes the injury or death of a patient. We applaud Rep. Sánchez for introducing the Fairness in Nursing Home Arbitration Act and ask Congress to act quickly to restore long-term care patients with their constitutional right to be heard by a judge and jury.”
Long Term Care Community Coalition Executive Director Richard J. Mollot – “LTCCC believes pre-dispute arbitration agreements are inherently unfair to residents and families. When a resident enters a facility, they are not likely to be in a position to truly consider what future problems may occur. Most people are overwhelmed by the situation and trust that the nursing home is providing them with paperwork to sign that is both necessary and in the resident’s best interest. Nobody knowingly enters a nursing home expecting that they will be abused or neglected.”
Public Citizen Counsel for Civil Justice and Consumer Rights Remington Gregg – “We thank Rep. Sánchez for being a champion for seniors. If seniors are injured, abused, or otherwise harmed, they and their families should have peace of mind that they will be able to hold corporate wrongdoers accountable in court and receive the justice they deserve.”
Center for Medicare Advocacy Policy Attorney Dara Valanejad – “Too often, nursing home residents and families enter into pre-dispute arbitration agreements in the midst of physical and emotional crises. The Fairness in Nursing Home Arbitration Act of 2019 will ensure that long-term care residents and those in community-based settings are not forced, coerced, or “requested” to waive their right to court proceedings before a dispute even arises. Our nation’s most vulnerable individuals deserve to be protected from these pre-dispute arbitration agreements.”
National Consumer Voice for Quality Long-Term Care Director of Advocacy & Outreach Robyn Grant – “The National Consumer Voice for Quality Long-Term Care thanks Congresswomen Sánchez and Schakowsky for their leadership in protecting nursing home residents and individuals receiving Medicaid-funded home and community -based services from forced pre-dispute arbitration agreements. Such agreements are fundamentally unfair to consumers of long-term services and supports in any setting. They pressure people to decide how to settle a dispute – which could involve gross negligence, abuse, or even death – before a dispute arises and without any information about the dispute. Once signed, the individual loses forever their constitutional right to pursue action in a court of law. These agreements take advantage of consumers at their most vulnerable and stack the deck against them by frequently allow the long-term care provider to select the arbitrator, the rules for the arbitration process, and where the arbitration will be held. But pre-dispute arbitration agreements harm more than the individual who is seeking justice and accountability. Because the agreements usually are confidential, the public, including those looking for a nursing home, will never know the nursing home’s full track record – no matter how bad – because it is hidden. We applaud both Congresswomen for their commitment to ending this shameful practice and upholding the rights of vulnerable individuals in need of care.”