Categoria: senior living

By Fred Schulte,

Kaiser Health News

Medicare Advantage plans for seniors dodged a major financial bullet recently as government officials gave them a reprieve for returning hundreds of millions of dollars in government overpayments — some dating back a decade or more.

The health insurance industry had long feared the Centers for Medicare & Medicaid Services would demand repayment of billions of dollars in overcharges the popular health plans received as far back as 2011.

But in a surprise action, CMS announced last month that it would require next to nothing from insurers for any excess payments they received from 2011 to 2017. CMS will not impose major penalties until audits for payment years 2018 and beyond are conducted, which have yet to be started.

While the decision could cost Medicare plans billions of dollars in the future, it will take years before any penalty comes due. And health plans will be allowed to pocket hundreds of millions of dollars in overcharges and possibly much more for audits before 2018. Exactly how much is not clear because audits as far back as 2011 have yet to be completed.

In late 2018, CMS officials said the agency would collect an estimated $650 million in overpayments from 90 Medicare Advantage audits conducted from 2011 to 2013, the most recent ones available. Some analysts calculated overpayments to plans of at least twice that much for the three-year period.

CMS is now conducting audits for 2014 and 2015.

The estimate for the 2011-13 audits was based on an extrapolation of overpayments found in a sampling of patients at each health plan. In these reviews, auditors examined medical records to confirm whether patients had the diseases for which the government reimbursed health plans to treat.

Through the years, those audits — and others conducted by government watchdogs — have found that health plans often cannot document that they deserved extra payments for patients they said were sicker than average.

The decision to take earlier audit findings off the table means CMS has spent tens of millions of dollars conducting audits as far back as 2011 — much more than the government will be able to recoup.

In 2018, CMS said it pays $54 million annually to conduct 30 of the audits. Without extrapolation for years 2011-17, CMS won’t come near to recouping that much.

CMS Deputy Administrator Dara Corrigan called the final rule a “commonsense approach to oversight.” Corrigan said she did not know how much money would go uncollected from years prior to 2018.

Health and Human Services Secretary Xavier Becerra, meanwhile, said the rule takes “long overdue steps to move in the direction of accountability.”

“Going forward, this is good news. We should all be happy that they are doing that (extrapolation),” said former CMS official Ted Doolittle. “I do wish they were pushing back further (and extrapolating earlier years). That would seem to be fair game.”

David Lipschutz, an attorney with the Center for Medicare Advocacy, said he was still evaluating the rule, though he added it was unclear whether the agency is using its entire authority.

“It is our hope,” Lipschutz said, “that CMS would use everything within their discretion to recoup overpayments made to Medicare Advantage plans.”

Mark Miller, the executive vice president of health care policy for Arnold Ventures — who formerly worked at the Medicare Payment Advisory Commission, a congressional advisory board — said extrapolating errors found in medical coding have always been a part of government auditing. (Kaiser Health News receives funding support from Arnold Ventures.)

“It strikes me as ridiculous to run a sample and find an error rate and then only collect the sample error rate,” he said, “as opposed to what it presents to the entire population or pool of claims.”

In January, KHN released details of the 90 audits from 2011 to 2013, which were obtained through a Freedom of Information Act lawsuit. The audits found about $12 million in net overpayments for the care of 18,090 patients sampled for the three-year period.

In all, 71 of the 90 audits uncovered net overpayments, which topped $1,000 per patient, on average, in 23 audits. CMS paid the remaining plans too little on average, anywhere from $8 to $773 per patient, the records showed.

Since 2010, the federal Centers for Medicare & Medicaid services has threatened to crack down on billing abuses in the popular health plans, which now cover more than 30 million Americans. Medicare Advantage, a fast-growing alternative to original Medicare, is run primarily by major insurance companies, including Humana, UnitedHealthcare, Centene and CVS/Aetna.

But the industry has successfully opposed extrapolating overpayments, even though the audit tool is widely used to recover overcharges in other parts of the Medicare program.

That has happened despite dozens of audits, investigations and whistleblower lawsuits accusing Medicare Advantage of costing taxpayers billions of dollars a year in overcharges.

CMS expected to collect $479 million from overpayments in 2018, the first year of extrapolation, Corrigan said. Over the next decade, she said, it could recoup $4.7 billion.

Medicare Advantage plans also face potentially hundreds of millions of dollars in clawbacks from a set of unrelated audits conducted by the Health and Human Services inspector general.

The audits include an April 2021 review that accuses a Humana Medicare Advantage plan in Florida of overcharging the government by nearly $200 million in 2015.

Carolyn Kapustij, the Office of the Inspector General’s senior adviser for managed care, said the agency has conducted 17 such audits that found widespread payment errors — on average, 69% for some medical diagnoses.

In these cases, Kapustij said, the health plans “did not have the necessary support (for these conditions) in the medical records, which has caused overpayments.”

“Although the MA organizations usually disagreed with us,” she added, “they almost always had little disagreement with our finding that their diagnoses were not supported.”

While CMS has taken years to conduct the Medicare Advantage audits, it has also faced criticism for permitting lengthy appeals that can drag on for years. These delays have drawn sharp criticism from the Government Accountability Office, the watchdog arm of Congress.

Leslie Gordon, an acting director of the GAO health team, said that until CMS speeds up the process, it “will fail to recover improper payments of hundreds of millions of dollars annually.”

KHN senior correspondent Phil Galewitz contributed to this report.

Kaiser Health News is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at Kaiser Family Foundation. KFF is an endowed nonprofit organization providing information on health issues to the nation.

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By Dr. Daniel H. LaMont,

Contributing writer 

Cardiovascular disease is the leading cause of death in adults.

And for older adults, there is an even greater cause for concern, since about 21.7% of American adults who art at least 65 reported having coronary heart disease, a stroke or both, according to the Centers for Disease Control and Prevention.

Older adults are statistically more likely to have heart disease for many reasons. Plaque rupture, atrial fibrillation, loss of vascular compliance, obesity, hypertension and diabetes all contribute to this increased incidence of cardiovascular disease.

Daniel H. LaMont, M.D., FACC, FSCAI, cardiologist, MemorialCare Heart & Vascular Institute at Saddleback Medical Center. (Photo courtesy of MemorialCare) The National Council on Aging notes that heart disease is a broad term that includes a variety of conditions, such as coronary artery disease, irregular heartbeat, problems with the heart valves, problems with the heart muscle and hereditary (congenital) defects.

Approximately 80% of heart disease deaths occur in people who are aged 65 or older, according to the American Heart Association. Dying from cardiovascular disease is 10 times more common than any other cause of death in seniors. No matter how old you get, knowing the risk factors of heart disease is the first step in preventing — or taking steps to reverse — heart disease, helping you live longer.

Know your risk for heart disease There are many behavioral factors that can contribute to an older adult being at risk for heart disease. But it’s important to know even as you age, you can still work to minimize risk factors. So don’t give up on yourself! Major risk factors for heart diseases include:

High blood pressure. High cholesterol. Smoking. Obesity. Diabetes. Lack of physical activity. Poor eating habits. Another factor that adds to older adults’ risk of heart disease is genetics. It is important to understand and know your family history of heart disease. Genetic factors sometimes play a role when it comes to high blood pressure, heart disease and other related conditions. And when genetic risks are combined with unhealthy lifestyle habits, it can increase the risk of heart disease greatly.

Know the symptoms of heart disease In the early stages of heart disease, symptoms are not always noticeable, especially in older adults. Since older adults tend to have more aches and pains, please don’t minimize any of these symptoms and always speak to your physician if you are feeling an onset of any of these symptoms with exertion:

Chest, shoulder, arm, neck, jaw or back pain or pressure. Shortness of breath when active, or while lying flat. Lightheadedness when standing up. Dizziness or imbalance when walking. Confusion. Headaches. Easy onset fatigue. Swelling in the ankles, feet, legs, stomach and/or neck. Intermittent weakness or numbness in an arm or leg. Intermittent loss of vision in one eye. Intermittent slurred speech. It is essential to visit your doctor regularly to help ensure your heart is healthy and to catch early signs of heart disease.

Preventing or lowering risk? When found early, heart disease is much easier to treat and manage than when it is in a later stage. It’s easier to take a walk around your house, for example, if you aren’t carrying an oxygen tank with you.

Here are some things you can do now to help lower your risk of heart disease:

Being more active: Start by walking around the house, gardening, doing water aerobics and looking into what classes your local senior center might offer. Talk with your doctor about the activities that would be best for you. Quit smoking: If you still smoke, it’s time to quit. There are many smoking cessation classes available specifically for seniors. Eat healthy: Follow a heart healthy diet by eating more fruits, vegetables and foods high in fiber. I’m sure you still have some of your favorite pies or dishes that may not be as healthy but try to limit those to special occasions. Stay hydrated: Seniors get dehydrated quicker than anyone else – as we age, our body starts to dry out more; you may notice it in your skin and hair. But seniors really should be mindful of drinking at least eight 8-ounce glasses of water a day. Lower your alcohol consumption: Alcohol, when paired with medicine, can have diminishing effects, so it’s important to not drink as much as you age. Manage your stress: Stress can manifest itself in older adults in more physical ways, such as headaches and insomnia – so be mindful of this. Control your diabetes: Follow your doctor’s advice to manage diabetes by taking prescribed medications as directed. Control your blood pressure and/or cholesterol: Don’t forget that it’s important to take medication. But lifestyle changes can always help you. Light exercise and choosing not to eat saturated fats or trans-fat foods can significantly improve your health. It is never too late to start taking care of your heart. No matter your age, it is important to have egular physicals and ask your doctor whether regular cardiovascular screenings and risk reduction visits make sense for you. Along with living a healthy lifestyle, heart evaluations can help detect heart disease early – at its most manageable stage.

Dr. Daniel Lamont is a cardiologist at MemorialCare Saddleback Medical Center and has been practicing for 20 years. He graduated from Brown University Medical School in 1991 and specializes in cardiology and interventional cardiology.

By Michelle Andrews,

Kaiser Health News

When Margarette Nerette arrived in the United States from Haiti, she sought safety and a new start.

The former human rights activist feared for her life in the political turmoil following the military coup that overthrew President Jean-Bertrand Aristide in 1991. A few years later, Nerette, then 29, left her two small children with her sister in Port-au-Prince, came to Miami on a three-month visa — and never went back.

In time, she was granted political asylum.

She eventually studied to become a nursing assistant, passed her certification exam and got a job in a nursing home. The work was hard and didn’t pay a lot, she said, but “as an immigrant, those are the jobs that are open to you.”

A few years later, her family joined her, but her children didn’t want to follow her career path. When she was a teenager, Nerette’s daughter, now 25, would ask, “Mom, why are you doing that?” Her daughter, Nerette said, considered the work underpaid and too physical.

After many years, Nerette, now 57, left nursing home work for a job with the Florida chapter of the labor union SEIU1199, which represents more than 25,000 health workers. As the local’s vice president for long-term care, she is keenly aware of staffing challenges that have plagued the industry for decades and will worsen as aging baby boomers stretch the limits of long-term care services.

The U.S. is facing a growing crisis of unfilled job openings and high staff turnover that puts the safety of older, frail residents at risk. In a tight labor market where job options are plentiful, long-term care jobs that are poorly paid and physically demanding are a tough sell. Experts say opening pathways for care workers to immigrate would help, but policymakers haven’t moved.

In the decade leading up to 2031, employment in health care support jobs is expected to expand by 1.3 million, a nearly 18% growth rate that outpaces that of every other major occupational group, according to the federal Bureau of Labor Statistics. These direct care workers include nurses of various types, home health aides, and physical therapy and occupational therapy assistants, among others.

Certified nursing assistants, who help people with everyday tasks like bathing, dressing and eating, make up the largest proportion of workers in nursing homes. In the decade leading up to 2029, nearly 562,000 nursing assistant jobs will need to be filled in the United States, according to a far-reaching report on nursing home quality published last year by the National Academies of Sciences, Engineering and Medicine.

But as the U.S. population ages, fewer workers will be available to fill those job openings in nursing homes, assisted living facilities and private homes. While the number of adults 65 and older will nearly double to 94.7 million from 2016 to 2060, the number of working-age adults will grow just 15%, according to an analysis of census data by PHI, a research and advocacy organization for older people and those with disabilities.

Immigrants can play a crucial role in filling those gaps, experts say. Already, about 1 in 4 direct care workers are foreign-born, according to a 2018 PHI analysis.

“We do think that immigrants are critical to this workforce and the future of the long-term care industry,” said Robert Espinoza, executive vice president of policy at PHI. “We think the industry would probably collapse without them.”

Nursing homes and other long-term care facilities have long struggled to maintain adequate staff. The problem worsened dramatically during the pandemic, when those facilities became hotbeds for coronavirus infections and deaths. More than 200,000 residents and staff members died during the first two years of the pandemic, representing about a quarter of all coronavirus-related deaths during that time.

Since March 2020, the long-term care industry has lost more than 300,000 jobs, bringing employment to a 13-year low of just more than 3 million, according to an analysis of BLS payroll data by the American Health Care Association and the National Center for Assisted Living.

Immigration policies that aim to identify potential workers from overseas to fill long-term care job slots could help ease the strain. But unlike other countries facing similar challenges, the U.S. generally hasn’t made attracting direct care workers from abroad a priority.

“Immigration policy is long-term care policy,” said David Grabowski, a professor of health care policy at Harvard Medical School, whose research focuses on the economics of aging and long-term care. “If we really want to encourage a strong workforce, we need to make immigration more accessible for individuals.”

Most of the roughly 1 million immigrants to the U.S. annually are family members of citizens, though some come in on employment visas, often for highly skilled jobs.

On his first day in office, President Joe Biden proposed comprehensive immigration reform that would have created a pathway to citizenship for undocumented workers and revised the rules for employment-based visas, among other things, but it went nowhere.

“There hasn’t been a lot of interest or political will behind opening up more immigration opportunities for mid- to lower-level care aides such as home health aides, personal health aides and certified nursing assistants,” said Kristie De Peña, vice president for policy and director of immigration policy at the Niskanen Center think tank.

The Biden administration didn’t respond to requests for comment.

Some local and regional organizations, though, are working to connect immigrants with health care jobs.

Ascentria Care Alliance provides social services, refugee resettlement and long-term care services in five New England states. With state and private philanthropic funding, the organization is beginning to help refugees from Ukraine, Haiti, Venezuela and Afghanistan get the supportive services they need — language, housing, child care — to enable them to take health care jobs at Ascentria’s long-term care facilities and those of health care partners.

The group has long helped refugees resettle and find jobs in traditional settings like warehouses or retailers, said Angela Bovill, president and CEO of Ascentria, which is based in Worcester, Massachusetts. “Now we’re looking at what it would take to move them into health care jobs.”

The alliance is applying to the Department of Labor for a grant to scale up the program.

“If we get it right,” Bovill said, “we’ll build a pathway and a pipeline to move at the fastest rate from immigrant to effective health care worker.”

Some long-term care experts say the U.S. can’t afford to drag its feet on putting policies in place to appeal to immigrants.

“We’re competing with the rest of the world, other countries that also want these workers,” said Howard Gleckman, a senior fellow at the Urban Institute.

Canada, for instance, is going all in on immigration. In 2022, it welcomed more than 430,000 new permanent residents, the most in its history. Immigration accounts for almost 100% of Canada’s labor force growth, and by 2036, immigrants are expected to make up 30% of the population, the government said.

In the U.S., immigrants account for about 14% of the population, according to an analysis of census data by the Migration Policy Institute.

Canada’s Economic Mobility Pathways Pilot aims to identify and recruit refugees who have skills Canadian employers need. In January, after visiting a refugee camp in Kenya, recruiters offered jobs in Nova Scotia to 65 continuing care assistants.

In a December survey of 500 U.S. nursing homes, meanwhile, more than half said staffing shortages have forced them to turn away new residents.

These staffing challenges, industry representatives said, are likely to become an even heavier lift, with more closed facilities, units or wings, after the Biden administration announced last year that it would establish minimum nursing home staffing requirements.

A government mandate alone won’t solve long-standing problems with inadequate training, pay, benefits or career advancement, experts said.

“Young people aren’t going to clean 10 to 15 patients for $15 an hour,” Nerette said. “They’ll go to McDonald’s. We need to face that reality and come up with a plan.”

Kaiser Health News is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at Kaiser Family Foundation. KFF is an endowed nonprofit organization providing information on health issues to the nation.