What are your options when you run out of money?
“My mom is running out of money in the assisted living, hospital or rehab, so she will have to go on Medicaid and live in a nursing home.” I have heard these words so many times, I can’t count them.
On most of these occasions, my role is to help the family make the decision to accept hospice for their loved one because they have waited so long, hoping the patient was going to get well and go home. But recently, I found a large gap between what the system has to offer in between independent living and the nursing home. A lot has to do with licensing and advertising.
In this case, the client was suffering from moderate dementia, she used a walker but had no other medical complications. Her heart was healthy and she didn’t have diabetes or COPD. She was living in a private residence for seniors, but not a licensed assisted living according to state law and therefore not covered by Medicaid. However, everyone assumed that because the residence offered room and board and everyone there used either a walker or a wheelchair, that this was an Assisted Living Facility. In fact, they were advertised on many web sites under the heading Assisted Living Facility. I don’t think this was the fault of the residence. There is simply no distinction on these websites between those that qualify for Medicaid and those that are private. It is up to the family to shop around.
The cost of the stay at most private residences is about $5000 a month, including assistance from a licensed home care agency that provided help with bathing, dressing and medication. Sometimes the bill can be as much as $7000 including Cable TV and other utility bills and personal services such as hair cuts and toe nail clipping. If the patient does not have diabetes, toe nail clipping is not covered under Medicare.
I was called in to help with the Medicaid application, pending the move from the independent residence to the nursing home. The financial paperwork had been with the nursing home for months. Since the nursing home accepted that I would be able to help the patient qualify for Medicaid, we were asked to speak to the admissions nurse to get a move in date. That’s when we found out that the patient did not medically qualify for admission to the nursing home, as she was able to perform most physical activities of daily living with a minimum of supervision. Even though she was not mentally able to live on her own, dementia is not considered a reason to confine a patient to a nursing home level of care. We realized that it would even be cruel to condemn the woman to a life of laying in bed or sitting in a wheelchair, just because her memory wasn’t what it used to be.
Now, here is where the gap in the system showed itself. No one could point me to where the client could find the level of care she needed that would be covered by Medicaid. The nursing home staff suggested someone might be able to take her into their home. Since the woman did not have any family, I was pointed to unlicensed homeowners who will take a persons social security check in exchange for room and board. I couldn’t accept that in all good conscience, so I pulled out my trusty SUN-B Directory. There I found Fred Altman, who I remembered is like a real estate agent for senior residences. He said there was only one place in about a 50 mile radius that would be appropriate.
As it turns out, the facility is licensed as an Adult Home and so can accept Medicaid, when the resident is in need of a higher level of assistance with activities of daily living, but not ready for a nursing home. The kicker here is that since the facility is set up to treat people requiring this higher level of care, many services that this client needs are included in the basic rent. Medication Management, assistance with bathing and dressing, making sure the resident gets to meals and activities are all covered. For this client, it meant that she would not even need to qualify for Medicaid as she had sufficient income to pay for her monthly expenses.
This was a very good ending to a story that could have gone another way. The person could have been made homeless without the intervention of the people at the original Senior Residence, who called the alarm early enough for something to be done. The woman could have been pushed into an inappropriate setting if the Nursing Home hadn’t been ethical about her qualifications. Or the Adult Home could have been full, as I am sure they will be soon, as more and more people live longer, but just need a little help.
by Caryn Isaacs, Patient Advocate http://gethealthhelp.com
Resources: Senior Umbrella Network of Brooklyn http://sunb.org ;
Fred Altman, http://www.ElderCareAdviceInc.com;
I usually don’t copy, but this is a must read article!
Where ‘Socialized Medicine’ Has a U.S. Foothold
By UWE E. REINHARDT
Doug Mills/The New York Times The Olympics’ opening ceremony included a tribute to Britain’s National Health Service, which American critics often depict as a failure of “socialized medicine.”
Uwe E. Reinhardt is an economics professor at Princeton. He has some financial interests in the health care field.
Last Friday’s exuberant celebration of Britain’s National Health Service during the opening ceremony for the 2012 Olympics, directed by the Oscar-winning filmmaker Danny Boyle, got me thinking about American attitudes about socialized medicine.
Today’s Economist
Perspectives from expert contributors.
As might be expected, the event elicited a few tut-tuts from Conservative members of Parliament, and more stern rebukes from the commentariat in the United States, most vehemently by Rush Limbaugh.
Bashing the N.H.S. has become a favorite ritual during any debate on health care reform on this side of the Atlantic. As the disgraceful treatment of Dr. Donald Berwick, former administrator of the Centers for Medicare and Medicare Services, illustrates, any American remarking positively on the N.H.S. runs the risk of being declared unfit to serve in government and vehemently attacked in the blogosphere.
The most humorous illustration of American N.H.S.-bashing was supplied during the heated health reform discussions in 2009 by Investor’s Business Daily. In an editorial, the paper asserted, “People such as scientist Stephen Hawking wouldn’t have a chance in the U.K., where the National Health Service would say the quality of life of this brilliant man, because of his physical handicaps, is essentially worthless.”
Dr. Hawking, who has lived and worked in Britain all of his life, responded: “I wouldn’t be here today if it were not for the N.H.S. I have received a large amount of high-quality treatment without which I would not have survived.”
Eventually, Prof. Ara Darzi, a former minister of health, head of surgery at Imperial College in London and Britain’s ambassador for health and life sciences, and Tom Kibasi of McKinsey & Company, an honorary lecturer at Imperial College, gently lectured American readers on this amusing episode and on the actual modus operandi of the N.H.S. The episode also opened a lively and sometimes bemused blog traffic in Britain.
Although I personally have never advocated adopting an N.H.S.-style approach to health reform in the United States, I have been puzzled for decades by the almost instinctive habit among many Americans of incessantly running down every other country’s approach to health care and health insurance.
Is this habit born of the deep-seated insecurity that might naturally arise from the cognitive dissonance of boasting “ours is the best health system in the world,” all the while beholding daily the travails and hand-wringing over the sometimes glaring shortcomings of the American health care system?
I have found that one effective way I can stop N.H.S.-bashing dead in its track is to ask bashers this simple question: “Why don’t you like my son?” I posed that question to a congressman who had berated “socialized medicine” during a hearing on health insurance reform at which I testified.
In response to the stunned look this question invariably elicits, I go on: ”You see, our son is a retired captain of the U.S. Marine Corps. He is an American veteran. Remarkably, Americans of all political stripes have long reserved for our veterans the purest form of socialized medicine, the vast health system operated by the U.S. Department of Veterans Affairs (generally known as the V.A. health system). If socialized medicine is as bad as so many on this side of the Atlantic claim, why have both political parties ruling this land deemed socialized medicine the best health system for military veterans? Or do they just not care about them?”
I must note that there is a widespread confusion in this country over the terms “social health insurance” and “socialized medicine.”
Among policy wonks, “social health insurance” is understood to be health insurance to which the individual makes contributions on the basis of ability to pay, rather than on the basis of health status. Such a system can be coupled, and often is, with purely private health care delivery systems, including for-profit enterprises. Canada, Taiwan, Japan, South Korea, Germany, the Netherlands and Switzerland come to mind.
Socialized medicine refers to systems that couple social health insurance with government-owned and operated health care facilities, such as Britain’s N.H.S. or the Hong Kong Hospital Authority, a still-appreciated legacy of British colonialism. Socialized medicine also typified the health systems operated by the former socialist countries in the Soviet orbit. Evidently, the V.A. health system perfectly fits the definition of socialized medicine.
Occasionally one does come across an American politician who mutters something about privatizing the V.A. health system. I doubt this idea would have much political traction, either as part of a party’s platform or in the presidential candidates’ campaign repertoire.
In fact, I would dare presidential candidates professing a distaste for socialized medicine to call openly for abolition of the V.A. health system in favor of a purely privatized system – e.g., a defined contribution system such as that advocated for Medicare by Representative Paul D. Ryan, Republican of Wisconsin and chairman of the House Budget Committee.
So far I have not received a satisfactory answer from detractors of “socialized medicine” to my question of why we have the V.A. health system when socialized medicine putatively is so evil. Perhaps some commentators on this blog will enlighten me.
Before responding, however, readers might consider these readings, which can be found in an Internet search on “V.A. Health Care and Quality”: a book by Phillip Longman, “The Best Care Anywhere: Why V.A. Health Care Is Better Than Yours”; an article on V.A. health care in the American Medical Association’s amednews.com, and, finally, from the Rand Corporation’s nationally recognized team of experts on the quality of health care in the United States this eye-opening report.
What’s Wrong with the American Health System?
What’s wrong with the American Health System? Misinformation-Disinformation and Lies. The American People, including most of our lawmakers do not understand how the health system works.
There are two parts to the American health system ,the delivery of care and the financing of care. In other countries there is only one answer to “how do we deliver care and how do we finance it?” In the US there are many thousands of answers.
In the US, the delivery of care is regulated by the Department of Health and the Department of Education in each State. Health Care providers are licensed to provide a defined service under a set of rules which include obtaining a level of education and experience and maintaining the proper facility and equipment. It is this part of the system that we point to when we say the American Health System is the best in the world.
However, the Financing of Care is regulated in many different ways. The Federal Government funds and creates the rules for Medicare. Each State receives some funding from the Federal Government for Medicaid coverage of the poor, while the State and Local Governments create the rules under which they will pay for that care.
Most people in the US get their coverage through private insurers, either through their employer or through an individual policy. Insurers can define the delivery system they will pay for, as long as they abide by the rules of their State for licensing of health providers and minimum regulations for reserves, showing that they can pay for the services they offered in their policy.
The Affordable Care Act (ACA) seeks to refine the guidelines underwhich States receive Federal Funding for Medicare and Medicaid and to mandate minimum standards for private insurers. It also intends to raise revenue to fund the changes through a new tax.
There is no question that it is a complicated system for which those who are healthy and have coverage are perfectly satisfied. It only becomes a problem when you are sick and need to find funding for your care. The opposition’s suggestion as to an alternative to the ACA is to allow the purchase of insurance across State lines, which would nullify the protections established by the State who represents the needs of their constituents.
Their other suggestions is to reform the laws under which a patient could receive damages in the case of malpractice. Their claim is that providers could lower their costs, which may be true to some extent, but is defensive medicine the only driving factor in rising health care costs?
As a small business owner, I am disappointed that the reform path chosen by our Government did not provide for a Public Option or even better for the Single Payer system that works so well for other countries. I am angry about the new tax. I would agree to pay for getting a comprehensive coverage package and to pay for my share of protecting the poor, however I do not see the ACA accomplishing this.
I am happy that there is a discussion about what our health care system needs because I don’t see either side laying down their misinformatiom-disinformation and lies long enough to find a solution to our funding problems.
Written by Caryn Isaacs, Patient Advocate and Health Policy Expert. Reprinted from LinkedIn group; Adult Children Caring for Aging Parents, discussion started by Ray Ashton 2nd, Founder, STAR Preventive Wellness – CEO, AFFECTS LLC Houston, Texas Area
You have to be in it to win it.
A leading physician practice management consultant called me today to ask about marketing a new Article 28 multi-specialty practice. I suggested to her that she look up the record on who was recently approved in NYS and to call them for their marketing plan. Are referrals still based on friendships or hospitall connections? Are Accountable Care Organizations or Insurance Plan Preferred Provider Organizations going to run the health care delivery system?
Here is the last chance for providers and others to be heard about how the ACA will be implemented in NYS. You or your organization can attend these meetings, no charge. lf you want your opinion in the record, make sure you put it in writing and send in advance or be there to testfy.
CON Redesign Special PHHPC Planning Committee,
PHHPC Committee and Full Council Meetings:
June – December 2012
6/21/12 – Albany Special Planning Committee: Driving Health System Improvement in New York State: Policy Priorities and Tools
7/25/12 – Albany Committee on Codes, Regulations, and Legislation
Committee on Public Health
Special Health Planning Committee: Innovations in Financing and Organizing Health Care: Implications for CON and Health Care Regulation
7/26/12 – Albany The Establishment and Project Review Committee
8/9/12 – Albany PHHPC Full Council
9/5/12 – Rochester Special Planning Committee: Regional Health Planning
9/19/12 – NYC Special Planning Committee: Establishment, Governance and Financial Feasibility
9/20/12 – NYC Regular PHHPC Committee
10/11/12 – NYC PHHPC Full Council
10/12/12 – NYC Special Planning Committee: Access and Public Need
10/30/12 – NYC Special Planning Committee: Review Draft Report
11/14/12 – Albany Special Planning Committee: Discuss Revised Report
11/15/12 – Albany Regular PHHPC Committee: Adoption of Report by Committee
Contact me if you have a question or comment. I get lots of comments on LinkedIn groups from professionals in the field. How about letting the public in on our conversations,
Fight Against Cost Shifting – Pricing vs Costs
One of my clients was in Mayo Clinic for a very severe illness. Mayo charged $50,000 for the week of care. My client feels that saving her life was certainly worth the cost. However, Medicare allowed only $800 of the billable services. For some of the itemized services, Medicare says the negotiated price was lower and therefore the patient would not owe the difference between the charged amount and what was paid. Her AARP Medigap policy payed the 20% co-pay of the reduced amount, considering that Medicare, the primary payor had negotiated the lower price.
The problem for the patient comes in where some of the itemized services were considered “uncovered services,” meaning there was no code for the service such as the hospital charged for an exam which included doing a test to determine the cause of the patients distress. It makes sense to most people that when you go to the doctor or hospital that first they exam you and then they do some tests based on their initial exam. Not to the insurance companies though. The test was considered an uncovered service because it was done on the same day as the exam. All right, I can see the test being part of the exam, but Medicare paid for the lower priced exam and not the higher costing test, which was needed to understand how to treat the patient.
In the current law which is a part of the Affordable Care Act (ACA) which has already been implemented (and has nothing to do with the mandate or patients using emergency rooms for primary care) the “regulations” (the provisions in the ACA) state that providers can charge the patient for “uncovered services.” So, Providers now realize that since the EOB reads “uncovered service,” they have the right to charge the patient for any “uncovered services,’ according to the insurance policy and the regulations.
Medicare is aware of this issue and their website, http://Medicare.gov states that they are looking into how this has been affecting beneficiaries, but at this time, they regret to say that the patient must pay the bill. This means that the language in the portions of the ACA that have already been implemented have caused this cost shifting.
In another demonstration of cost shifting, a client went to the hospital in pain which was determined to come from a very large kidney stone, which caused a severe infection. After a stinit was put in to hold the stone from causing more damage, the patient was sent home, still in pain with antibiotics to wait for the infection to clear. A week later, she was to report to her PCP to get a referral for a urologist. She waited three hours in the office only to be told that the doctor was too busy and a Physician’s Assistant would write the referral. Another week went by until the Urology appointment. The Urologist made a referral to a facility where a procedure could be done to break up the stone. The patient was in a lot of pain, so she asked the Urologist office if they could do anything to hurry up the appointment process. They were able to schedule the procedure for the following week at a facilty an hour away, which was the only one approved by her plan. Then, the day before the facility was to do perform the procedure, the patient gets a call that they have to reschedule because the patient only had the referral to the Urologist from the PCP and not for the procedure. Specialists cannot give referrals because that might be considered a conflict of interest. So now the patient has to wait another week to see the PCP’s Physician Assistant for a referral to the facility to remove the stone, which they were not qualified to do in the first place which is why they sent the patient to the Urologist. The facility schedules patients a month in advance, so now instead of the expedited procedure, the patient will need to go to the back of the line. Then, the paitent will need to go back to the hospital to have the stent removed. All the while, doctors and hospital are being paid for visits and the patient is paying co-pays out of pocket for visits and medications. In this situation, the insurance company and the patient are over paying due to over-regulation.
Until the doctors (AMA) and hospitals (AHA) do the hard work of determining a pricing mechanism for services instead of allowing the insurers to use a lowest negotiated rate policy, we will continue to see cost shifting with the patients on the losing end.
I am hoping that today’s students are learning how the regulations are developed, so that our new policy wonks will demand a real economic solution to health care costs instead of a political one.
The health system is changing before our very eyes.
We recently have a number of complaints from patients who have been stuck with large medical and hospital bills for things that used to be covered. Patients are going in for an ultrasound and being billed privately for use of the room. People are getting medications in the hospital and getting a gigantic co-pay bill because the medication wasn’t submitted correctly. As the health care system makes changes to protect themselves from the Affordable Care Act, how do patients make sure they have enough coverage? In this article, firefighters are questioning which coverage will be better, the one offered by the government to the public or the one they have for themselves?
The Public Health and Health Planning Council releases final recommendations for CON
A Mission and Vision for Certificate of Need in the 21st Century
Mission of New York’s CON Program
New York’s Certificate of Need (CON) program, together with other programs and policies, promotes the alignment of health care resources with community health needs in order to:
• preserve and promote access to high quality health care;
• contain health care costs and promote cost-effective health care; and
• promote healthy communities.
Read More….
Here’s the webcast to explain all the changes proposed by the council, including licensure of facilities and home care agencies. http://www.totalwebcasting.com/view/?id=nysdoh
How did I get so much stuff?
I met Ron Alford of Disaster Masters®, Inc yesterday at SUN-B. Many seniors don’t think of themselves as hoarders, they just haven’t gotten rid of things they value in many many years. Ron doesn’t use the word hoarders, he calls it disposophobia. You can see more about how to get help at his web site, http://theplan.com.
NYS Public Health and Health Planning Committee to unveil recommendations for redesign.
STATE OF NEW YORK
PUBLIC HEALTH AND HEALTH PLANNING COUNCIL
SPECIAL MEETING OF THE COMMITTEE ON HEALTH PLANNING
June 21, 2012
10:00 a.m.
Empire State Plaza
OGS Concourse, Meeting Room #7
Albany, New York
I. Welcome
II. Our Charge
III. Our Work Plan
IV.Driving Health System Improvement in NYS – Policy Priorities and Tools
a. Delivery System Performance
b. Policy Priorities and Tools
c. Certificate of Need – Functions and National Comparison
d. Licensure and Surveillance
V. Public Comment
Rumor has it.
Sorry if you got all excited about a post I reprinted about EFT being endorsed by the Psychological Association. It seems, it was just a rumor, taken out of context from someone who was hoping it would be true.
On the bright front, we have been hearing that the NYS Health Planning Committee has speeded up the contingent approval process for licensed home health care agencies. We believe this is due to the requirements that Medicaid patients in nursing homes and long term home health care situations will be forced to select a managed care program or will be assigned to one in October of this year. Many companion agencies are rushing to get their license so as not to be left out of the Medicaid marketplace.
AGINGICON.COM
Have you lived a life of accomplishment, doing what fulfills
you? Have you reached an age where things are harder to do?
Are you a leader and you know that you cannot do it alone?
Then, you are an Aging Icon.
My name is Caryn Isaacs.
Having been at the helm of developing hundreds of healthcare
businesses and running several multi-million-dollar companies,
my journey includes pioneering a physician-owned HMO and
active engagement in Healthcare Reform.
As a Patient Advocate, my company, GetHealthHelp, LLC,
specializes in crafting solutions that enable Aging Icons to
continue pursuing their passions.
An example is a 98-year-old author, playwriter and poet who is
suffering from fibromyalgia and thought that all her work
would be forgotten. I found a way for her legacy to continue by
publishing them as books and now working on having them
made into films.
If this sounds like something of interest, let’s meet to talk
further.
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