Of course, it takes more than just discipline, such as making monthly contributions every month into the company 401(k), or setting aside savings to accomplish future goals: college, vacations and emergency funds. What’s needed is a step-by-step ‘blueprint’ highlighting the important considerations as we advance through the years.
Your employer’s 401(k).
For some time now, employers have shifted their retirement offerings away from the traditional pension (defined benefit) plan to a defined contribution option, the 401(k). Such plans are usually sponsored by an employer who relies on a plan administrator, such as a Vanguard or Fidelity, to offer employees a select number of mutual funds.
Today, in keeping with defined contribution programs, the offering of ‘target-date’ mutual funds is becoming an appealing option for investors, as noted on the Investopedia website. Commonly referred to as ‘hybrid’ funds, this class of mutual funds…
“…automatically resets the asset mix of stocks, bonds and cash equivalents in its portfolio according to a selected time frame that is appropriate for a particular investor.”
With a 401(k) plan employees are always in control of their funds, and in some cases the employer will even match contributions on a percentage basis. Aside from the obvious tax benefit to employees that derive from reducing taxable income, companies receive a major tax break as well.
When it comes to matching funds, an example might be a 3% match by the employer: if you’re making $50,000 a year, the ‘match’ would total $1,500, which is money from the employer’s pocket direct into your 401(k).
Investing through the ‘ages.’
Young investors should start money away for retirement in their 20’s, so by the time they’re in their 50’s, their portfolio has more opportunity for growth.
In later years, it’s highly recommend to purchase a long-term care (LTC) insurance policy; this, to protect the assets in place from the costs of in-home care, or even the expense of a nursing home. In some instances, a blend of insurance along with the LTC policy is a smart choice.
Ideally, too, your retirement funds should receive a boost once you’ve whittled down, or eliminated, any outstanding debts. This could be car payments, credit cards and, of course, mortgage payments.
How do you plan to live in your ‘60s and beyond?
Remember that the backbone of your retirement funding will, for the most part, come from your Social Security benefits. Or, in other cases from federal or corporate pensions.
Obviously, the best mileage from your income streams at this point will depend on when you decide to start receiving your Social Security, and/or pension benefits; the former benefits increase by 8% a year until you begin drawing on it—-better than an annuity or CD’s, for sure!
A key resource during these years is an experienced financial advisor to help guide you in your investment decisions, and who can also help you with a withdrawal strategy to optimize your retirement savings
Most of all, and since the ’80’s are now referred to as the “new ’60s,” it is paramount that our health is given as much attention as our financial situation.
How will you ‘spend’ your retirement?
Today’s shift among retirees is not so much on how they “should spend their hard-earned money in retirement, but how they should spend their time.”
As such, the author of “The One Minute Manager,” Ken Blanchard, re-packages the traditional notion of retiring: “Refire! Don’t Retire,” and concentrate on the inner aspects of one’s psyche, such as developing new boundaries that test the “intellectual, physical and spiritual” vein during those later years.
Learn more about the importance of developing an estate plan, one that will help maximize your tax savings while protecting your financial assets. Contact us to start the conversation today.
The post Retirement plans should provide a ‘blueprint’ for investing throughout the Golden Years. appeared first on The Elder Care Firm.
The post Retirement plans should provide a ‘blueprint’ for investing throughout the Golden Years. first appeared on SEONewsWire.net.]]>Of course, it takes more than just discipline, such as making monthly contributions every month into the company 401(k), or setting aside savings to accomplish future goals: college, vacations and emergency funds. What’s needed is a step-by-step ‘blueprint’ highlighting the important considerations as we advance through the years.
Your employer’s 401(k).
For some time now, employers have shifted their retirement offerings away from the traditional pension (defined benefit) plan to a defined contribution option, the 401(k). Such plans are usually sponsored by an employer who relies on a plan administrator, such as a Vanguard or Fidelity, to offer employees a select number of mutual funds.
Today, in keeping with defined contribution programs, the offering of ‘target-date’ mutual funds is becoming an appealing option for investors, as noted on the Investopedia website. Commonly referred to as ‘hybrid’ funds, this class of mutual funds…
“…automatically resets the asset mix of stocks, bonds and cash equivalents in its portfolio according to a selected time frame that is appropriate for a particular investor.”
With a 401(k) plan employees are always in control of their funds, and in some cases the employer will even match contributions on a percentage basis. Aside from the obvious tax benefit to employees that derive from reducing taxable income, companies receive a major tax break as well.
When it comes to matching funds, an example might be a 3% match by the employer: if you’re making $50,000 a year, the ‘match’ would total $1,500, which is money from the employer’s pocket direct into your 401(k).
Investing through the ‘ages.’
Young investors should start money away for retirement in their 20’s, so by the time they’re in their 50’s, their portfolio has more opportunity for growth.
In later years, it’s highly recommend to purchase a long-term care (LTC) insurance policy; this, to protect the assets in place from the costs of in-home care, or even the expense of a nursing home. In some instances, a blend of insurance along with the LTC policy is a smart choice.
Ideally, too, your retirement funds should receive a boost once you’ve whittled down, or eliminated, any outstanding debts. This could be car payments, credit cards and, of course, mortgage payments.
How do you plan to live in your ‘60s and beyond?
Remember that the backbone of your retirement funding will, for the most part, come from your Social Security benefits. Or, in other cases from federal or corporate pensions.
Obviously, the best mileage from your income streams at this point will depend on when you decide to start receiving your Social Security, and/or pension benefits; the former benefits increase by 8% a year until you begin drawing on it—-better than an annuity or CD’s, for sure!
A key resource during these years is an experienced financial advisor to help guide you in your investment decisions, and who can also help you with a withdrawal strategy to optimize your retirement savings
Most of all, and since the ’80’s are now referred to as the “new ’60s,” it is paramount that our health is given as much attention as our financial situation.
How will you ‘spend’ your retirement?
Today’s shift among retirees is not so much on how they “should spend their hard-earned money in retirement, but how they should spend their time.”
As such, the author of “The One Minute Manager,” Ken Blanchard, re-packages the traditional notion of retiring: “Refire! Don’t Retire,” and concentrate on the inner aspects of one’s psyche, such as developing new boundaries that test the “intellectual, physical and spiritual” vein during those later years.
Learn more about the importance of developing an estate plan, one that will help maximize your tax savings while protecting your financial assets. Contact us to start the conversation today.
The post Retirement plans should provide a ‘blueprint’ for investing throughout the Golden Years. appeared first on The Elder Care Firm.
The post Retirement plans should provide a ‘blueprint’ for investing throughout the Golden Years. first appeared on SEONewsWire.net.]]>
Investors today must take a long-view of the market if they want a decent chance of increasing their portfolios before retiring.
The idea is to die young as late as possible – Ashley Montague
…and in between those years, particularly without a long-term care insurance (LTC) policy, one must certainly make sure they’ll have the assets to cover nursing home or in-home care expenses!
But that’s a lot to ask of the portfolio nowadays, given the beating investments took during the 2008 economic debacle, and the paltry interest rates from bonds…not to mention the uncertainty of returns in the long-term.
Indeed, and speaking of ‘long term,’ investors today must take a long-view of the market if they want a decent chance of increasing their portfolios before retiring, or meeting other challenging goals like help send the kids to college or vocational school.
But what constitutes the ‘long term’ view?
Financial gurus say it needs to be “much longer than five years.” As an example, in the five years ending in 2012 the market gave us a “net loss.” But over the past five years, and ending in 2013, the rewards were double-digit annualized gains.
Investors may be swayed by mutual fund companies touting five-year gains in their marketing messages, and forgot about how they should not be expecting the same returns—or better—from those funds in the future.
Still, the stock market returns in that five-year duration have been impressive. For example, by the end of 2013 the market showed the following gains:
- Annualized five-year: 15.4 percent—without adding in dividends!
- Annualized five-year: 17.9 percent with dividends added in.
The best advice for the long-term investor, notes James W. Paulsen, chief investment strategist at Wells Capital Management, always comes back to “basic diversification and asset allocation.”
“If you follow the basics, that’s 80 percent of it,” he said. “Guys like me are trying to improve your returns for what’s left after that.”
In the meantime, it’s always prudent to develop an estate plan that will protect one’s portfolio, including any real estate, from liquidation to pay any future nursing home expense, or assisted living costs, for example.
Making an alternative ‘bet’ on long-term care coverage.
As such, investors looking to add a long-term care policy to their portfolio may have come across the news about the consolidation within this sector of the insurance industry, including the fact that a lot of companies are no longer offering LTC policies.
Moreover, those companies offering coverage today, like Genworth, have instituted huge premium increases to keep this part of their business profitable.
Of course, push-back is not uncommon among existing customers, and some opt to cut out a few of their policy features, such as future “inflation protection” in hopes of keeping premiums unchanged.
The debate about the need for insurance of any kind can be couched in the analogy akin to buying homeowners insurance: if your house doesn’t burn down, you’ll be hard-pressed to find a homeowner who regrets buying it in the first place.
No surprise, then, that some insurance companies have seen an opportunity to offer a type of hybrid-LTC (“combo”) using life insurance, or “retirement-income annuities.” The ‘annuity’ part of the equation is sold as a savings vehicle to lock-in a “lifetime stream of income.”
Generally, a buyer will purchase their “tax-advantage” annuity to fall back on it’s future value to cover care at home, or in a facility. The important thing is to understand that the benefits from these hybrid’ policies can vary enormously.
Yet another option…
Some insurance companies offer a product with “LTC acceleration,” which can provide an “advanced payment” if long-term costs incurred. This feature is used when the payment is close to the actual death benefit of the policy.
Contact us to discuss your estate planning needs, including your options for long-term care, power-of-attorney as well as guidance with veteran’s benefits.
The post Assisted living costs and nursing home expenses can be covered by ‘combo’ insurance policies. appeared first on Estate Planning Lawyers | Elder Law Attorneys | Brighton | Novi | Livonia Elder Law Attorneys.
The post Assisted living costs and nursing home expenses can be covered by ‘combo’ insurance policies. first appeared on SEONewsWire.net.]]>
A continuing care retirement community is able to offer progressive levels of care as they become necessary.
In today’s uncertain economic times marked by roller-coaster markets and flat-line wages, leave it to a certain segment of Michigan seniors and retirees who are choosing to live in bigger homes instead of taking a more common route of downsizing during their retirement years.
In fact, according to a recent report by Merrill Lynch and Age Wave, 49% of retirees in their survey chose not to downsize in “their last move.” Moreover, 30% were electing to move into a much larger home. Such choices obviously belong to a retirement sector quite “confident with their investments.”
More importantly, the survey revealed that about 20% selected a larger home not only to accommodate family visits, but also to provide the space for families to live with them in the future—the survey indicates that 16% of the retirees responding actually had a boomerang child living with them.
Accompanying this ongoing trend is the notion that a larger home may actually provide better in-home care options; this, even though larger homes bring higher taxes, maintenance and even association fees.
Still, and while larger homes can make in-home care a more viable option, the increase interest in other choices, such as assisted living and even nursing home options continues unabated.
Staying in the home.
It may not be surprising that around 90% of seniors polled by AARP showed a preference for ‘aging in place, or staying in their home after the age of 65. Often, that might mean customizing rooms by adding ramps, or installing stairlifts, or even moving an upper bedroom to the first floor.
But when health conditions deteriorate for those ‘aging in place,’ seniors can still receive hospice care in their homes during those end-of-life stages—funded by Medicare and Medicaid services.
Is ‘assisted living’ covered by Medicare/Medicaid?
Of course, the home may not be a viable option, because of expense and minor health issues. As such seniors may favor an assisted living facility. Unfortunately, neither Medicare and Medicaid will pick up room-or-board costs.
However, these facilities accept seniors who may be at different ‘tiers’ of medical need, thereby affecting the resident’s monthly charges. Generally, the more ambulatory you are, the cheaper the overall costs.
By law, these facilities can only offer extra care up to a certain level; then, other options may have to be considered. But if you are fortunate to have long-term care insurance, the policy may provide some “in-home” help while you are in an assisted-living setting.
Continuing Care Retirement Facilities (CCRCs)
Generally, these facilities require a one-time ‘entry fee’, and then monthly payments that reflect the range of services and amenities offered. Ideally, as their ability to live independently decreases, seniors are able to receive progressive care at the CCRC—a viable solution to the universal question of how to avoid nursing home costs.
CCRCs are normally set up to provide around-the-clock care when needed. Of course, with this level of assistance comes higher monthly costs.
‘Assistance’ from your 401(k).
Congress tried to include long-term care (LTC) for all U.S. citizens in the Affordable Care Act (ACA), but it was axed. Instead, the hope is that the IRS will eventually allow us to use our 401(k) to at least pay for LTC premiums, thereby lessening the agency’s current definition of “hardship” cases.
IRS’s existing hardship withdrawal rules do provide for tax-free withdrawals to cover what is considered to be “significant medical expenses.” But it remains questionable that the hardship rules will change; this, owing to the potential decrease in tax revenues that could result.
To start the conversation about the importance of an overall estate plan, including the need for long-term health coverage, contact us today.
The post How to avoid nursing home costs: CCRCs may provide the progressive care needed. appeared first on Estate Planning Lawyers | Elder Law Attorneys | Brighton | Novi | Livonia Elder Law Attorneys.
The post How to avoid nursing home costs: CCRCs may provide the progressive care needed. first appeared on SEONewsWire.net.]]>Partners, appearing in a recent issue of Pulse, a publication for Florida’s LTC community, if the
attending physician is unavailable, a “physician extender” such as a Nurse Practitioner or
Physician Assistant can stroke the pen. However, care must be taken to determine that this person
does not have an indirect employment relationship with the facility. This can get dicey, but as
long as this person works for an entity other than the facility, that has an agreement with the
facility that solely involves the performance of “delegated physician tasks”, not “general nursing
services”, he or she can sign the certification.The post WHO MAY SIGN MEDICARE PART A CERTIFICATIONS? first appeared on SEONewsWire.net.]]>
term care facilities is a growing problem. After extensive research, Diane Bunn, MSc, and
colleagues said they could not identify any proven strategies for increasing fluid intake for the
LTC resident. This would lead to the inevitable conclusion that LTC professionals need to make
developing such strategies a priority.The post LTC PROFESSIONALS ADVISED TO “GET CREATIVE” IN ENCOURAGING RESIDENTS TO INCREASE FLUID INTAKE first appeared on SEONewsWire.net.]]>
By Jordan Rau
Kaiser Health News
More than 2,000 hospitals — including some nationally recognized ones — will be penalized by
the government starting in October because many of their patients are readmitted soon after
discharge, new records show.
Together, these hospitals will forfeit more than $280 million in Medicare funds over the next
year as the government begins a wide-ranging push to start paying health care providers based on
the quality of care they provide.
With nearly one in five Medicare patients returning to the hospital within a month of discharge,
the government considers readmissions a prime symptom of an overly expensive and
uncoordinated health system. Hospitals have had little financial incentive to ensure patients get
the care they need once they leave, and in fact they benefit financially when patients don’t
recover and return for more treatment.
Nearly 2 million Medicare beneficiaries are readmitted within 30 days of release each year,
costing Medicare $17.5 billion in additional hospital bills. The national average readmission rate
has remained steady at around 19 percent for several years, even as many hospitals have worked
harder to lower theirs.
The penalties, authorized by the 2010 health care law, are part of a multipronged effort by
Medicare to use its financial muscle to force improvements in hospital quality. In a few months,
hospitals also will be penalized or rewarded based on how well they adhere to basic standards of
care and how patients rated their experiences. Overall, Medicare has decided to penalize 71
percent of the hospitals whose readmission rates it evaluated, the records show.
The penalties will fall heaviest on hospitals in New Jersey, New York, the District of Columbia,
Arkansas, Kentucky, Mississippi, Illinois and Massachusetts, a Kaiser Health News analysis of
the records shows. Hospitals that treat the most low-income patients will be hit particularly hard.
A total of 307 hospitals nationally will lose the maximum amount allowed under the health care
law: 1 percent of their base Medicare reimbursements. Several of those are top-ranked
institutions, including Hackensack University Medical Center in New Jersey, North Shore
University Hospital in Manhasset, N.Y. and Beth Israel Deaconess Medical Center in Boston, a
teaching hospital of Harvard Medical School.
“A lot of places have put in a lot of work and not seen improvement,” said Dr. Kenneth Sands,
senior vice president for quality at Beth Israel. “It is not completely understood what goes into an
institution having a high readmission rate and what goes into improving” it.
Sands noted that Beth Israel, like several other hospitals with high readmission rates, also has
unusually low mortality rates for its patients, which he says may reflect that the hospital does a
good job at swiftly getting ailing patients back and preventing deaths.
Penalties Will Increase Next Year
The maximum penalty will increase after this year, to 2 percent of regular payments starting in
October 2013 and then to 3 percent the following year. This year, the $280 million in penalties
comprise about 0.3 percent of the total amount hospitals are paid by Medicare.
According to Medicare records, 1,910 hospitals will receive penalties less than 1 percent; the
total number of hospitals receiving penalties is 2,217. Massachusetts General Hospital in Boston,
which U.S. News last month ranked as the best hospital in the country, will lose 0.53 percent of
its Medicare payments because of its readmission rates, the records show. The smallest penalties
are one hundredth of a percent, which 49 hospitals will receive.
Dr. Eric Coleman, a national expert on readmissions at the University of Colorado School of
Medicine, said the looming penalties have captured the attention of many hospital executives.
“I’m not sure penalties alone are going to move the needle, but they have raised awareness and
moved many hospitals to action,” Coleman said.
The penalties have been intensely debated. Studies have found that African-Americans are more
likely to be readmitted than other patients, leading some experts to be concerned that hospitals
that treat many blacks will end up being unfairly punished.
Hospitals have been complaining that Medicare is applying the rule more stringently than
Congress intended by holding them accountable for returning patients no matter the reason they
come back.
Hospitals That Serve Poor Are Hit Harder Than Others
Some safety-net hospitals that treat large numbers of low-income patients tend to have higher
readmission rates, which the hospitals attribute to the lack of access to doctors and medication
these patients often experience after discharge. The analysis of the penalties shows that 80
percent of the hospitals that have a lot of low-income patients will lose Medicare funds in the
fiscal year starting in October. Sixty-seven percent of the hospitals treating few poor patients are
going to be penalized, the analysis shows.
“It’s our mission, it’s good, it’s what we want to do, but to be penalized because we care for
those folks doesn’t seem right,” said Dr. John Lynch, chief medical officer at Barnes-Jewish
Hospital in St. Louis, which is receiving the maximum penalty.
“We have worked on this for over four years,” Lynch said, but those efforts have not substantially
reduced the hospital’s readmissions. He said Barnes-Jewish has tried sending nurses to patients’
homes within a week of discharge to check up on them, and also scheduled appointments with a
doctor at a clinic, but half the patients never showed. This spring, the hospital established a team
of nurses, social workers and a pharmacist to monitor patients for 60 days after discharge.
“Some of the hospitals that are going to pay penalties are not going to be able to afford these
types of interventions,” said Lynch, who estimated the penalty would cost Barnes-Jewish $1
million.
Atul Grover, chief public policy officer for the Association of American Medical Colleges, called
Medicare’s new penalties “a total disregard for underserved patients and the hospitals that care
for them.” Blair Childs, an executive at the Premier healthcare alliance of hospitals, said: “It’s
really ironic that you penalize the hospitals that need the funds to manage a particularly difficult
population.”
Medicare disagreed, writing that “many safety-net providers and teaching hospitals do as well or
better on the measures than hospitals without substantial numbers of patients of low
socioeconomic status.” Safety-net hospitals that are not being penalized include the University of
Mississippi Medical Center in Jackson and Denver Health Medical Center in Colorado, the
records show.
Bill Kramer, an executive with the Pacific Business Group on Health, a California-based
coalition of employers, said the penalties provide “an appropriate financial incentive for hospitals
to do the right thing in terms of preventing avoidable readmissions.”
The government’s penalties are based on the frequency that Medicare heart failure, heart attack
and pneumonia patients were readmitted within 30 days between July 2008 and June 2011.
Medicare took into account the sickness of the patients when calculating whether the rates were
higher than those of the average hospital, but not their racial or socio-economic background.
The penalty will be deducted from reimbursements each time a hospital submits a claim starting
Oct. 1. As an example, if a hospital received the maximum penalty of 1 percent and it submitted
a claim for $20,000 for a stay, Medicare would reimburse it $19,800.
The Centers for Medicare & Medicaid Services has been trying to help hospitals and community
organizations by giving grants to help them coordinate patients’ care after they’re discharged.
Leaders at many hospitals say they are devoting increased attention to readmissions in concert
with other changes created by the health law.
Sally Boemer, senior vice president of finance at Mass General, said she expected readmissions
will drop as the hospital develops new methods of arranging and paying for care that emphasize
prevention. Readmissions “is a big focus of ours right now,” she said.
Gundersen Lutheran Health System in La Crosse, Wis., and Intermountain Medical Center in
Murray, Utah, were among 887 hospitals where Medicare determined the readmission rates were
acceptable. Those hospitals will not lose any money, nor will another 346 hospitals that had too
few cases for Medicare to evaluate. On average, the readmissions penalties were lightest on
hospitals in Utah, South Dakota, Vermont, Wyoming and Oregon, the analysis shows. Idaho was
the only state where Medicare did not penalize any hospital.
Even some hospitals that won’t be penalized are struggling to get a handle on readmissions.
Michael Baumann, chief quality officer at the University of Mississippi Medical Center, said
in-house doctors had made headway against heart failure readmissions by calling patients at
home shortly after discharge. “It’s a fairly simple approach, but it’s very labor intensive,” he said.
The problems afflicting many of the center’s patients—including obesity and poverty that makes
it hard to afford medications—make it more challenging. “It’s a tough group to prevent
readmissions with,” he said.
Compression Therapy Reduces Blood Clots in Stoke Patients, Study Finds
New research shows that inexpensive leg compression devices help prevent fatal blood clots in stroke patients.
The thigh-length sleeves promote blood flow by periodically filling with air and gently squeezing the legs. Vascular PRN, based in Tampa, Fla., is a leading national distributor of intermittent pneumatic compression (IPC) therapy equipment. Greg Grambor, the company’s president, commented on the study. “Compression therapy has been around for over 20 years,” Grambor said. “Many doctors have already come to rely on this equipment for safe, effective, and affordable prevention of deep vein thrombosis. I’m glad this new research was done, and I hope it will help convince more doctors to give it a try.” Deep vein thrombosis (DVT) is the formation of a blood clot inside a vein deep within the body. It is common in stroke patients and immobile patients and can also occur in healthy people on long flights where movement is restricted. When a clot detaches, it can then become lodged in the arteries of the lungs, causing a potentially life-threatening pulmonary embolism.
The study involved nearly 3,000 stroke patients at over 100 hospitals across the United Kingdom. Results showed 8.5 percent of patients treated with compression devices developed blood clots, versus 12.1 percent of patients who received alternative treatments. “Many patients at risk of DVT are prescribed blood thinning drugs,” Grambor added. “But these drugs increase the risk of bleeding, which is quite dangerous for stroke patients as it may lead to bleeding in the brain.”
So far, no study has conclusively shown that blood thinners increase the survival rate of stroke patients. Doctors at the European Stroke Conference, held in London on May 31, 2013, discussed the study’s findings. Professor Martin Dennis of the University of Edinburgh said that the UK’s guidelines for treatment of stroke should be revised to recommend IPC treatment for all patients at high risk of DVT. Currently, they only recommend it in cases where blood thinners are unsuccessful or too risky.
Each year, some 15 million people worldwide suffer a stroke. One third of strokes are fatal and another third result in permanent disability.
The post ADVANTAGE – Long Term and Post Acute Care first appeared on SEONewsWire.net.]]>By Jordan Rau
Kaiser Health News
More than 2,000 hospitals — including some nationally recognized ones — will be penalized by
the government starting in October because many of their patients are readmitted soon after
discharge, new records show.
Together, these hospitals will forfeit more than $280 million in Medicare funds over the next
year as the government begins a wide-ranging push to start paying health care providers based on
the quality of care they provide.
With nearly one in five Medicare patients returning to the hospital within a month of discharge,
the government considers readmissions a prime symptom of an overly expensive and
uncoordinated health system. Hospitals have had little financial incentive to ensure patients get
the care they need once they leave, and in fact they benefit financially when patients don’t
recover and return for more treatment.
Nearly 2 million Medicare beneficiaries are readmitted within 30 days of release each year,
costing Medicare $17.5 billion in additional hospital bills. The national average readmission rate
has remained steady at around 19 percent for several years, even as many hospitals have worked
harder to lower theirs.
The penalties, authorized by the 2010 health care law, are part of a multipronged effort by
Medicare to use its financial muscle to force improvements in hospital quality. In a few months,
hospitals also will be penalized or rewarded based on how well they adhere to basic standards of
care and how patients rated their experiences. Overall, Medicare has decided to penalize 71
percent of the hospitals whose readmission rates it evaluated, the records show.
The penalties will fall heaviest on hospitals in New Jersey, New York, the District of Columbia,
Arkansas, Kentucky, Mississippi, Illinois and Massachusetts, a Kaiser Health News analysis of
the records shows. Hospitals that treat the most low-income patients will be hit particularly hard.
A total of 307 hospitals nationally will lose the maximum amount allowed under the health care
law: 1 percent of their base Medicare reimbursements. Several of those are top-ranked
institutions, including Hackensack University Medical Center in New Jersey, North Shore
University Hospital in Manhasset, N.Y. and Beth Israel Deaconess Medical Center in Boston, a
teaching hospital of Harvard Medical School.
“A lot of places have put in a lot of work and not seen improvement,” said Dr. Kenneth Sands,
senior vice president for quality at Beth Israel. “It is not completely understood what goes into an
institution having a high readmission rate and what goes into improving” it.
Sands noted that Beth Israel, like several other hospitals with high readmission rates, also has
unusually low mortality rates for its patients, which he says may reflect that the hospital does a
good job at swiftly getting ailing patients back and preventing deaths.
Penalties Will Increase Next Year
The maximum penalty will increase after this year, to 2 percent of regular payments starting in
October 2013 and then to 3 percent the following year. This year, the $280 million in penalties
comprise about 0.3 percent of the total amount hospitals are paid by Medicare.
According to Medicare records, 1,910 hospitals will receive penalties less than 1 percent; the
total number of hospitals receiving penalties is 2,217. Massachusetts General Hospital in Boston,
which U.S. News last month ranked as the best hospital in the country, will lose 0.53 percent of
its Medicare payments because of its readmission rates, the records show. The smallest penalties
are one hundredth of a percent, which 49 hospitals will receive.
Dr. Eric Coleman, a national expert on readmissions at the University of Colorado School of
Medicine, said the looming penalties have captured the attention of many hospital executives.
“I’m not sure penalties alone are going to move the needle, but they have raised awareness and
moved many hospitals to action,” Coleman said.
The penalties have been intensely debated. Studies have found that African-Americans are more
likely to be readmitted than other patients, leading some experts to be concerned that hospitals
that treat many blacks will end up being unfairly punished.
Hospitals have been complaining that Medicare is applying the rule more stringently than
Congress intended by holding them accountable for returning patients no matter the reason they
come back.
Hospitals That Serve Poor Are Hit Harder Than Others
Some safety-net hospitals that treat large numbers of low-income patients tend to have higher
readmission rates, which the hospitals attribute to the lack of access to doctors and medication
these patients often experience after discharge. The analysis of the penalties shows that 80
percent of the hospitals that have a lot of low-income patients will lose Medicare funds in the
fiscal year starting in October. Sixty-seven percent of the hospitals treating few poor patients are
going to be penalized, the analysis shows.
“It’s our mission, it’s good, it’s what we want to do, but to be penalized because we care for
those folks doesn’t seem right,” said Dr. John Lynch, chief medical officer at Barnes-Jewish
Hospital in St. Louis, which is receiving the maximum penalty.
“We have worked on this for over four years,” Lynch said, but those efforts have not substantially
reduced the hospital’s readmissions. He said Barnes-Jewish has tried sending nurses to patients’
homes within a week of discharge to check up on them, and also scheduled appointments with a
doctor at a clinic, but half the patients never showed. This spring, the hospital established a team
of nurses, social workers and a pharmacist to monitor patients for 60 days after discharge.
“Some of the hospitals that are going to pay penalties are not going to be able to afford these
types of interventions,” said Lynch, who estimated the penalty would cost Barnes-Jewish $1
million.
Atul Grover, chief public policy officer for the Association of American Medical Colleges, called
Medicare’s new penalties “a total disregard for underserved patients and the hospitals that care
for them.” Blair Childs, an executive at the Premier healthcare alliance of hospitals, said: “It’s
really ironic that you penalize the hospitals that need the funds to manage a particularly difficult
population.”
Medicare disagreed, writing that “many safety-net providers and teaching hospitals do as well or
better on the measures than hospitals without substantial numbers of patients of low
socioeconomic status.” Safety-net hospitals that are not being penalized include the University of
Mississippi Medical Center in Jackson and Denver Health Medical Center in Colorado, the
records show.
Bill Kramer, an executive with the Pacific Business Group on Health, a California-based
coalition of employers, said the penalties provide “an appropriate financial incentive for hospitals
to do the right thing in terms of preventing avoidable readmissions.”
The government’s penalties are based on the frequency that Medicare heart failure, heart attack
and pneumonia patients were readmitted within 30 days between July 2008 and June 2011.
Medicare took into account the sickness of the patients when calculating whether the rates were
higher than those of the average hospital, but not their racial or socio-economic background.
The penalty will be deducted from reimbursements each time a hospital submits a claim starting
Oct. 1. As an example, if a hospital received the maximum penalty of 1 percent and it submitted
a claim for $20,000 for a stay, Medicare would reimburse it $19,800.
The Centers for Medicare & Medicaid Services has been trying to help hospitals and community
organizations by giving grants to help them coordinate patients’ care after they’re discharged.
Leaders at many hospitals say they are devoting increased attention to readmissions in concert
with other changes created by the health law.
Sally Boemer, senior vice president of finance at Mass General, said she expected readmissions
will drop as the hospital develops new methods of arranging and paying for care that emphasize
prevention. Readmissions “is a big focus of ours right now,” she said.
Gundersen Lutheran Health System in La Crosse, Wis., and Intermountain Medical Center in
Murray, Utah, were among 887 hospitals where Medicare determined the readmission rates were
acceptable. Those hospitals will not lose any money, nor will another 346 hospitals that had too
few cases for Medicare to evaluate. On average, the readmissions penalties were lightest on
hospitals in Utah, South Dakota, Vermont, Wyoming and Oregon, the analysis shows. Idaho was
the only state where Medicare did not penalize any hospital.
Even some hospitals that won’t be penalized are struggling to get a handle on readmissions.
Michael Baumann, chief quality officer at the University of Mississippi Medical Center, said
in-house doctors had made headway against heart failure readmissions by calling patients at
home shortly after discharge. “It’s a fairly simple approach, but it’s very labor intensive,” he said.
The problems afflicting many of the center’s patients—including obesity and poverty that makes
it hard to afford medications—make it more challenging. “It’s a tough group to prevent
readmissions with,” he said.
Compression Therapy Reduces Blood Clots in Stoke Patients, Study Finds
New research shows that inexpensive leg compression devices help prevent fatal blood clots in stroke patients.
The thigh-length sleeves promote blood flow by periodically filling with air and gently squeezing the legs. Vascular PRN, based in Tampa, Fla., is a leading national distributor of intermittent pneumatic compression (IPC) therapy equipment. Greg Grambor, the company’s president, commented on the study. “Compression therapy has been around for over 20 years,” Grambor said. “Many doctors have already come to rely on this equipment for safe, effective, and affordable prevention of deep vein thrombosis. I’m glad this new research was done, and I hope it will help convince more doctors to give it a try.” Deep vein thrombosis (DVT) is the formation of a blood clot inside a vein deep within the body. It is common in stroke patients and immobile patients and can also occur in healthy people on long flights where movement is restricted. When a clot detaches, it can then become lodged in the arteries of the lungs, causing a potentially life-threatening pulmonary embolism.
The study involved nearly 3,000 stroke patients at over 100 hospitals across the United Kingdom. Results showed 8.5 percent of patients treated with compression devices developed blood clots, versus 12.1 percent of patients who received alternative treatments. “Many patients at risk of DVT are prescribed blood thinning drugs,” Grambor added. “But these drugs increase the risk of bleeding, which is quite dangerous for stroke patients as it may lead to bleeding in the brain.”
So far, no study has conclusively shown that blood thinners increase the survival rate of stroke patients. Doctors at the European Stroke Conference, held in London on May 31, 2013, discussed the study’s findings. Professor Martin Dennis of the University of Edinburgh said that the UK’s guidelines for treatment of stroke should be revised to recommend IPC treatment for all patients at high risk of DVT. Currently, they only recommend it in cases where blood thinners are unsuccessful or too risky.
Each year, some 15 million people worldwide suffer a stroke. One third of strokes are fatal and another third result in permanent disability.
The post ADVANTAGE – Long Term and Post Acute Care first appeared on SEONewsWire.net.]]>by Brian Garavaglia
Older adults have sexual needs, which have often been minimized by the rest of the population. Furthermore, older adults that live in nursing home environments also have sexual needs that often are left unaddressed. Although addressing the topic has often been a sticky subject, a British nursing home has recently made the news by addressing the sexual needs of their elderly in a less than commonly accepted therapeutic modality. They have used prostitutes! Chaseley nursing home in Eastbourne, England has allegedly been using prostitutes to come into the facility to address the sexual needs of their older adult clientele. The Times of London writes that those that have these special sexual encounters meet with the prostitute in a special designated room of the facility that is often identified by a hanging “red sock” on the door to in form everyone that the room is currently being used for the sexual therapeutic intervention. A former manager for the nursing care center says that the nursing home’s use of prostitutes, which supposedly are acquired through a “third party contact,” helps to serve the sexual needs of the elderly. According to the staff member, not only is this serving a therapeutic need of the individual, but once their sexual needs are satisfied, it helps to address the needs of the institutional environment as well, by preventing residents from touching or groping other residents due to unsatisfied sexual needs.
A note from the editor of this blog: Prostitution is a legal business activity in England. The only place in the USA where prostitution is legal is the state of Nevada. If your facility is not in Nevada, proceed with caution!
Emeritus Gets Clobbered – Is it fair?
by Steve Moran
It was painful to read the news reports about the Emeritus guilty verdict. After reading the first article about the case a few weeks ago, I assumed Emeritus was going to get dinged on this one,but it was unclear how bad it would be. I first wrote about it in this article: Case Study – “Suit:Facility let woman ‘waste away’”. According to the story in the March 6, Sacramento Bee Story,the jury found Emeritus to be guilty, finding that “that an employee, officer, director or a managing agent acted with recklessness, malice, oppression and fraud.” The family was given an initial award of more than $4,000,000 which will likely be reduced to around $250,000 because of statutory pain and suffering limits. Then on Friday the jury awarded an additional $23 million in punitive damages. In the damage story, it came out that Emeritus had made a pretrial settlement offer of $3.5 million suggesting that from the very beginning they were expecting to get hurt.
What it Means
Emeritus is not known as a company that scrimps on resident care. In fact the Emeritus people I know have a huge commitment to providing quality care and services to their resident. It seems pretty clear this was an isolated problem at one community, with one resident . . . something that happened 5 years ago. Don’t get me wrong, I do think it was probably not unreasonable that Emeritus pay something.
That being said . . .
To take one single incident and use it to imply “recklessness, malice, oppression and fraud” is a huge stretch. This is particularly true because in Emeritus is a good company and runs good senior communities. It is particularly frustrating that the Sacramento Bee was essentially a shill for the plaintiff attorneys. They ran at least 3 stories that were heavily slanted against Emeritus. Most egregious is it appears that the article on closing arguments only covered the plantiff’s side and not the Emeritus defense. That is not reporting. To be honest, it appears there were some real problems with this particular situation:
●Several people have wondered if this woman should have ever been admitted. It is a good question, but without seeing the specific facts, it seems to me that it was a reasonable, better quality of life for the resident, decision.
●It sounds like this woman was frail and was probably assisted with bathing, so the fact that the decubitus ulcers were not caught, documented, reported and addressed earlier is problematic.
●This has to be the worst nightmare for operators, because assuming there was a problem, it could very well come down to one or two staff members who didn’t do the things should have done.
●It seems unlikely that whatever happened had a substantial impact on the resident’s longevity which makes the $23 million look ridiculous.
●There seem to be several “facts” that proved Emeritus provided substandard care, that even if true, don’t seem to have substantive relevance to the case. The one that really caught my eye was the allegation that on at least one occasion, there was no dedicated night shift memory care staff member (or at least no record of it). This seems to be mostly emotional smoke without fire;surely not an ideal thing, but the implication that somehow this caused the community to miss the skin problems makes no sense
●I feel particularly bad for all the hardworking dedicated Emeritus team members who work hard each day providing great care for their seniors that have now been tainted.
●It suggests it is now open season, at least in California, for assisted living providers. Again something that will make it harder to provide great care for seniors.
In truth, this week and in the weeks to follow, the fine providers of assisted living, includingthose who work for Emeritus will continue to provide quality compassionate care to seniors in the state of California. This case and the on-going threat of litigation will force senior communities to be more careful, to expend more time and energy on protecting themselves from predatory attorneys. This in turn means higher costs.
Union contracts drive 5 Connecticut nursing homes into bankruptcy.
By Bill McMorris
The Washington Free Beacon
Lucrative union contracts have driven five Connecticut nursing homes at the center of a labor dispute into bankruptcy. HealthBridge Management has entered five of its nursing homes into Chapter 11 bankruptcy to escape labor contracts that left the company losing $1.3 million each month, according to senior vice president of labor relations Lisa Crutchfield. “The centers have a bright future if they can operate under labor agreements that reflect today’s financial realities, but the fact is the centers will not survive unless we have relief from the crushing burden of unsustainable labor costs, especially the spiraling costs of pension and health care obligations,” Crutchfield said in a press release. The nursing homes’ costs have soared after negotiating lush contracts with the politically powerful Service Employees International Union Local 1199 NE in 2004, according to the company. The company spent nearly 50 percent more on employee benefits than the average Connecticut nursing home. “There is no getting around the fact that SEIU District 1199 labor agreements are the leading reason for nursing home closures in Connecticut. That’s bad for patients, employees, physicians and the communities they serve,”Ms. Crutchfield said. “In our case, the union’s collective bargaining agreements hobble the centers with labor costs that are well above state averages and which are simply unsustainable.” The nursing homes are asking a New Jersey bankruptcy court to amend the contracts since the union has not accepted concessions on pay and benefits. “This bankruptcy filing is the latest in along string of actions by HealthBridge aimed at avoiding their legal obligations to more than 600 hardworking nursing home caregivers across Connecticut and at chipping away at the quality of care for patients—a cynical evasion of responsibility to Connecticut working families and their communities,” District 1199 president David Pickus said. HealthBridge was left with few options after the embattled National Labor Relations Board ordered the company to rehire 600 striking union members despite allegations that the workers endangered patients during a July walkout. The Connecticut State Police are investigating whether union members mixed up patient medical records and identification documents during the strike.
Lorraine Mulligan, a veteran nurse, pleaded with the NLRB to keep the accused union members away from patients. “The nature and severity of the … incidents … put the safety, health, and well-being of the residents of those facilities in immediate jeopardy,” she said in a legal brief filed by HealthBridge. “A court order requiring the reinstatement of any of them or additionally those who had knowledge of sabotage and failed to act would expose the residents to immediate danger and put them at risk of suffering serious harm or death.” HealthBridge and Care One,another nursing home company, are suing the union on charges of racketeering and extortion in connection to the walkout and other instances of alleged vandalism. The bankruptcy declaration will put that suit on hold for the time being, according to a source familiar with the case. The company claims it is just the latest victim of financial giveaways to the union. SEIU 1199represents 19,000 workers in Connecticut and has contracts in place at nearly 30 percent of state nursing homes. Nearly 70 percent of state nursing home bankruptcies have emerged in centers with SEIU contracts in place, according to HealthBridge.
Conquering C. difficile in LTC
by Pamela Tabar, Senior Editor, Long Term
Living Clostridium difficile (C. diff.) leads to 14,000 deaths per year in the United States, and the numbers are on the rise. The illness often plagues those who have received antibiotics,exacerbated by the fact that C. diff itself is resistant to antibiotic treatments. A single infected patient costs an average of $35,000 to treat, according to the newly updated Guide to Preventing Clostridium difficile Infections released yesterday. The virulent microbe and the challenges it poses across healthcare settings is the topic of a two-day educational conference this week hosted by the Association for Professionals in Infection Control and Epidemiology (APIC). C. diff outbreaks can be especially difficult to contain and eradicate within long-term and post-acutecare settings, said Phenelle Segal, RN, CIC, president of Infection Control Consulting Services, Delray Beach, Fla., in her presentation “Practical Strategies to Control the Spread of C. difficile in Healthcare,” broadcast during the 2013 Clostridium difficile Educational and Consensus Conference. The community-based nature of skilled nursing facilities (SNFs) often creates special problems when caring for residents with C. diff, especially if there is no way to cohort infected residents. Semi-private rooms with shared bathrooms can cause issues if a resident needs the toilet immediately, yet using bedside commodes or bedpans can pose risks to caregivers. The ideal protocol would be to isolate infected residents, but it’s not practical or even possible in most long-term care settings, Segal says. “You can’t just move them. It’s their bedroom in their home, they have all their things set up and their pictures on the wall. it’s a huge challenge for long-term care.” One thing caregivers can do is control what happens upon entering and exiting the resident’s room. The use of gloves and gowns is crucial since the disease is capable of surviving on surfaces for five months and also spreads via spores, Segal explains. Vibrant disagreement surrounds the effectiveness of alcohol-based hand sanitizers vs. hand-washing.Alcohol-based sanitizers are appropriate in many instances, but they are not a silver bullet for everything. For example, hand-washing is crucial if the skin comes into contact with feces, since alcohol-based hand sanitizers cannot penetrate protein material, Segal says. “We’ve come a long way with hand hygiene, but we still have a long way to go. One of the biggest problems in LTCis the injudicious use of antimicrobials.” Segal also suggests that all LTC facilities form an antimicrobial stewardship program to educate all staff, including non-medical departments like housekeeping. Stewardship techniques include Positive Deviance and Team STEPPS, but Segal says regardless of the approach, teams should include housekeeping, administration and pharmacists as well as nurses and physicians. “The best approach is a group of healthcare workers who are experts in different areas united as a team,” she says. APIC’s Guide to Preventing Clostridium difficile Infections encourages SNFs to use the following strategies when caring for a resident with C. diff.:
●Gloves should be put on before entering and taken off before exiting the resident’s room.
●If a bedpan is needed, use a disposable one. For commodes, consider disposable liners.
●Suspend the use of rectal thermometers.
●Don’t share medical devices or equipment among infected and non-infected residents.
●If a roommate is unavoidable, choose someone who is not taking antibiotics and is healthy enough to fend off infections.
●Anything that has come in contact with fecal material from an infected patient should beconsidered infectious material. Proper cleaning and/or proper disposal is essential.
●Cleaning products must be able to kill the C. diff spores as well as the cells in order to beeffective. The Environmental Protection Agency considers bleach-based or strong hydrogenperoxide disinfectants to be the best spore-killers.
Policy Experts Agree: The U.S. System for Financing Long-Term Care is Crumbling
By Howard GleckmanAmerica’s system for financing long-term care is failing, and the window for creating a paymentsystem that works is rapidly closing. That was the conclusion of a morning-long expert sessionsponsored last week by the SCAN Foundation. While the participants differed on specificsolutions, most agreed on four key issues:
●The existing system for funding paid long-term supports and services is built on a wobblythree-legged stool: low private savings, an underfunded Medicaid program, and a hobbled privatelong-term care insurance market.
●The solution must include an affordable way for Americans to prefund their long-term care costs. This could include tapping financial assets or home equity, or buying insurance (either government, private, or some combination of both). Low-income people would require some form of safety net protection.
●Any future system should finance high-quality long-term supports and services that are well-integrated with medical care. This is especially important since recipients of care services suffer from chronic disease or injury that often requires complex medical interventions.
●There is currently no political consensus on how to do any of this.
That is where everyone agreed. Here is where they did not:
Several panelists focused on ways to enhance private insurance, where the market for traditional long-term care coverage has effectively collapsed. A paper by Marc Cohen of Lifeplans, Inc. and professors Richard Frank and Neale Mahoney of Harvard described a broad package of design changes that might make policies more attractive. Their ideas include simplifying and standardizing insurance products, indexing premiums annually instead of requiring carriers to ask for big rate increases every few years, allowing insurers to sell high-deductible plans (where buyers could be responsible for as much as two years of LTC costs), and better educating consumers about the price of long-term care and the limited government resources available to pay for it. They also propose industry-funded reinsurance pools that would protect in insurers against unanticipated risks. Another suggestion: Require that companies over a certain size offer LTC insurance and force workers to buy unless they make an active choice to reject insurance.They also recommend new highly-targeted government subsidies, such as tax credits, to encourage moderate-income consumers to purchase long-term care insurance. Finally, they suggest linking long-term care and health insurance, an idea I raised last year. Several of their proposals, such as catastrophic coverage and standardized plan designs, are aimed at substantially lowering rates. Expanding the role of employers may be especially critical since 80 percent of workers currently have no access to coverage through their jobs, according to a separate paper by Jeremy Pincus and colleagues at the insurance industry consulting firm Forbes Consulting Group. Like Cohen, Frank, and Mahoney; Pincus also believes an employer mandate would significantly boost the number of workers who would buy LTC insurance. But all that may not be enough.Other conference participants felt that even with these broad-based changes, voluntary private insurance would remain unattractive for many people. As a result, some sort universal coverageis the only way to make LTC insurance truly affordable for middle-income households.Voluntary insurance, even with reforms, would remain out of reach for tens of millions of middle-income people. Anne Tumlinson of the consulting firm Avalere Health, Josh Wiener of RTI International and their co-authors found that mandatory insurance would be significantly less expensive than voluntary coverage. Tumlinson said that maintaining the voluntary system would do little more than preserve the unworkable status quo. Insurance officials tell me privately that, even in the best case, perhaps 20 percent of Americans would buy voluntary LTC insurance. Perhaps another one-third have lifetime incomes so low that they can’t be expected to pay for their own care, either through savings or insurance, and will need some sort of public support. That leaves perhaps half the country at risk. The challenge for policy makers and the market is to figure out what will work for them. The SCAN program was a great start, but much more needs to be done.
The post ADVANTAGE – Long Term and Post Acute Care first appeared on SEONewsWire.net.]]>
by Alyssa Gerace
While some herald the Affordable Care Act as a much-needed reform bill that will change the face of the healthcare industry, others say it may contribute to forcing up to half of the nation’s hospitals and long-term care facilities into a merger or out of business altogether in upcoming years.
A lot of factors play into the possibility of widespread distress among smaller hospital systems and skilled nursing facility operators, including ongoing pressure on state Medicaid budgets, past Medicare cuts to the skilled nursing industry, and the $716 billion taken from Medicare in the next decade to help fund President Obama’s monumental healthcare reform bill.
“I think the smaller facilities will have a very difficult road going forward, and up to half of the hospitals and long-term care facilities are probably not going to make it,” says William Day,president and CEO of Pennsylvania-based St. Barnabas Health System. “The single-purpose facilities that only offer nursing services will be the most vulnerable.”
Both non-profit and for-profit senior care communities and hospitals that are smaller and already have small margins may be in a particularly tricky situation.
“There have been a lot of mergers already, even with hospitals,” Day says. “Sometimes we can predict the future by seeing what’s happening with ‘sister’ institutions. Hospitals have been joining together for a long time now, because they think it’s better for their survival, in terms of centralized purchasing and other economies of scale. Will that happen in the long-term care industry? No doubt.”
In the next 10 years, the skilled nursing industry will essentially contribute $14.6 billion to healthcare reform in the form of Medicare cuts, says Paul Bach, executive vice president at Genesis Health Care.
“While the industry wants to participate with other healthcare provider groups with the reform, at the same time, we’re concerned with the viability of the industry, coupled with other factors,” hes ays, citing frozen Medicaid rates as an example. “That has a significant impact on nursing facilities. There’s significant concern around the industry’s sustainability.”
In order to avoid the vulnerability that can accompany offering only one type of skilled nursing service, Genesis is looking for ways to prepare for what’s ahead.
“There’s a lot of focus on cost reduction: how can we make cuts to operating costs in our facilities that will not lead to a negative impact on quality, and how can we do that without experiencing much in the way of a reduced workforce?” Bach says.
At the same time, Genesis is positioning its communities to take advantage of other, more beneficial aspects of the ACA that can result in shared cost-savings. This includes participating in accountable care organizations (ACOs) and partnering with health systems and home healthcare agencies as part of a larger managed care movement to reduce hospital re-admissions,thereby helping hospitals avoid reimbursement penalties from Medicare for re-hospitalizations above a certain threshold.
Many larger skilled nursing chains are taking similar steps, but not all nursing homes have the scale or ability to do this.
“For smaller operators, they’re under the same pressure large, multi-location facilities are under,and there’s a need for them to be progressive and proactive in how they plan to respond to what’sin the ACA,” says Bach. “We expect there would be more consolidation within the industry as aresult of reimbursement cuts and the types of policy innovations that are taking place.”
At this point, it’s hard to tell how exactly healthcare reform, along with the fiscal cliff andMedicare and Medicaid-related budgetary concerns, will impact the skilled nursing industry.
“[The ACA] is a landmark reform that can change the landscape [of the industry] in unseen ways,” says Daniel Bernstein, an analyst with Stifel Nicolaus. “It will take a couple years to play out and see how operators adjust. There are pressures, and there’s a lot of speculation with consolidation within the industry. There are going to be some changes to the industry structure in the next couple of years.”
Those changes could come from large operators who want to continue to gain more scale, he says, or from family-run operators who don’t want to deal with the rapid changes that are happening with reimbursements and healthcare reform.
Although many of the major healthcare REITs are tending to avoid skilled nursing—mindful of valuations they’re given for diversifying into non-publicly reimbursed assets such as medical office buildings or senior housing assets—others, such as Omega Healthcare Investors(NYSE:OHI) and LTC Properties, Inc. (NYSE:LTC) are taking advantage of the lack of interest in skilled nursing assets to buy them at good yields, says Bernstein.
“REITs are still the primary consolidator of healthcare real estate across all the asset classes,including skilled nursing,” he says. “You could see some acceleration of M&A at some point depending on how healthcare reform and budget concerns shape up. With additional reimbursement pressure on operators, you’re likely to see more consolidation.”
Hospitals Face Pressure to Avert Re-admissions
By JORDAN RAU
After years of gently prodding hospitals to make sure discharged patients do not need to return,the federal government is now using its financial muscle to discourage re-admissions.THE NEW OLD AGE New Efforts to Close Hospitals’ Revolving Doors Spurred by new financial penalties that Medicare started imposing on places with too many re-admissions, hospitals are doing more outreach to make sure patients are following their discharge program. Medicare last month began levying financial penalties against 2,217 hospitals it says have had too many re-admissions. Of those hospitals, 307 will receive the maximum punishment, a 1 percent reduction in Medicare’s regular payments for every patient over the next year, federal records show. One of those is Barnes-Jewish Hospital in St. Louis, which will lose$2 million this year. Dr. John Lynch, the chief medical officer, said Barnes-Jewish could absorb that loss this year, but “over time, if the penalties accumulate, it will probably take resources away from other key patient programs.” The crackdown on re-admissions is at the vanguard of the Affordable Care Act’s effort to eliminate unnecessary care and curb Medicare’s growing spending, which reached $556 billion this year. Hospital inpatient costs make up a quarter of that spending and are projected to grow by more than 4 percent annually in coming years, according to the Congressional Budget Office. The readmission penalties will recoup about $300 million this year. But the goal is to pressure hospitals to pay attention to what happens to their patients after they walk out the door. The penalties have captured the attention of hospitals, and many are trying to improve their supervision of discharged patients’ recoveries. “I’ve been doing this for over two decades and talking to hospital leaders about re-admissions, and I used to get polite but blank stares,” said Dr. Eric Coleman, a professor at the University of Colorado Anschutz Medical Campus who has devised widely adopted methods to reduce hospitalizations. “Now they’repaying attention.” With nearly one in five Medicare patients returning to the hospital within a month — about two million people a year — re-admissions cost the government more than $17 billion annually. Hospitals’ traditional reluctance to tackle re-admissions is rooted in Medicare’s payment system. Medicare generally pays hospitals a set fee for a patient’s stay, so the shorter the visit, the more revenue a hospital can keep. Hospitals also get paid when patients return. Until the new penalties kicked in, hospitals had no incentive to make sure patients didn’t wind upcoming back. The maximum penalty is set to double next October and then reach 3 percent of reimbursements in October 2015. Medicare also is expanding the list of conditions it will assess in setting punishments. Right now it only evaluates re-admissions of heart attack, heart failure and pneumonia patients, counting every rebound, even ones not related to the original reason for hospitalization. The penalties are based on readmission rates in the past and applied to future payments for all Medicare patients. Researchers say that while some re-admissions are unavoidable, many are caused by the short shrift hospitals have given patients on their way out.Jonathan Blum, principal deputy administrator for the Centers for Medicare and Medicaid Services, said the penalties had helped galvanize hospitals’ efforts to avoid re-admissions. “We’ve seen a small but significant reduction,” he said. “That tells me we’ve focused the industry on improvement.” Medicare’s tough love is not going over well everywhere. Academic medical centers are complaining that the penalties do not take into account the extra challenges posed by extremely sick and low-income patients. For these people, getting medicine and follow-up care can be a struggle. At Barnes-Jewish Hospital, Dr. Lynch said physicians from all over the Midwest referred their sickest heart patients to his facility for transplants and other major interventions. But those patients can skew his hospital’s re-admissions numbers, he said: “The weaker your heart, the more advanced your emphysema, the more likely you are to be re-admitted to the hospital.” Dr. Lynch said Barnes-Jewish set up follow-up appointments for patients who didn’t have their own doctors. But about half of the patients never showed up, he said, even after the hospital made reminder phone calls and arranged for free rides. Sending nurses to see patients at home did not significantly reduce readmission rates either, he said. “Many of us have been working on this for other reasons than a penalty for many years, and we’ve found it’s very hard to move,” Dr. Lynch said. He said the penalties were unfair to hospitals with the double burden of caring for very sick and very poor patients. “For us, it’s not a re-admissions penalty,” he said. “It’s a mission penalty.” Various studies, including one commissioned by Medicare, have found thatthe hospitals with the most poor and African-American patients tended to have higher re-admission rates than hospitals with more affluent and Caucasian patients. But the studies also determined that some safety-net hospitals performed better than average, showing that hospitals can overcome the challenges posed by the kinds of patients they treat. In some ways, the debate parallels the one on education — specifically, whether educators should be held accountable for lower rates of progress among children from poor families. “Just blaming the patients or saying‘it’s destiny’ or ‘we can’t do any better’ is a premature conclusion and is likely to be wrong,” said Dr. Harlan Krumholz, director of the Center for Outcomes Research and Evaluation at Yale-New Haven Hospital, which prepared the study for Medicare. “I’ve got to believe we can do much,much better.” Some researchers fear the Medicare penalties are so steep, they will distract hospitals from other pressing issues, like reducing infections and surgical mistakes and ensuring patients’ needs are met promptly. “It should not be our top priority,” said Dr. Ashish Jha, a professor at the Harvard School of Public Health who has studied re-admissions. “If you think of all the things in the Affordable Care Act, this is the one that has the biggest penalties, and that’s just crazy.” With pressure to avert re-admissions rising, some hospitals have been suspected of sending patients home within 24 hours, so they can bill for the services but not have the stay-counted as an admission. But most hospitals are scrambling to reduce the number of repeat patients, with mixed success. A few days after Eda Laurion was discharged from the Banner Del E. Webb Medical Center near Phoenix after treatment for her congestive heart failure in August,a nurse showed up at her house. “She helped explained the medicines I’m taking, the side effects,what they do for you,” said Ms. Laurion, 91, of Sun City West. Still, re-admissions can’t always be prevented. The nurse, Sue Koner, sent Ms. Laurion back to the hospital after two weeks for dangerously low sodium caused by an un-diagnosed kidney problem. However, Ms. Laurion avoided re-hospitalization in October when Ms. Koner deduced that her hallucinations were a reaction to an antibiotic. Overseeing former patients is expensive and time-consuming, so many hospitals are relying on financing from community health organizations and foundations. Ms. Koner works for Sun Health, a foundation-supported nonprofit. Since Sun Health started its program in November 2011, only nine of 213 patients have been readmitted. Dr. Krumholz said hospitals should think of re-admissions as a challenge to overcome. “One day, we’ll look back,”he said, “and we’ll be incredulous that one out of every five patients ended up back in the hospital.”
The Ten Most Common Nursing Home Violations
By Long Term Care Solutions
Pro Publica analyzed 262,500 deficiencies with its u Nursing Home Inspect tool, which includes deficiencies identified by government regulators and the U.S. Centers for Medicare and Medicaid Services over the past three years. Since releasing this information on its website this summer,has added details of historical violations found in nursing homes. The agency now releases narrative reports of these problems from a home’s last three inspection cycles — or about three years. Here is their list of the 10 regulations most commonly violated by nursing homes:
• Facility is Free of Accident Hazards: 17,331 • Facility Establishes Infection Control Program: 14,186 • Provide Necessary Care for Highest Practicable Well-Being: 13,401 • Store/Prepare/ Distribute Food Under Sanitary Conditions: 11,746 • Develop Comprehensive Care Plans: 9,070 • Services Provided Meet Professional Standards: 8,986 • Clinical Records Meet Professional Standards: 7,962 • Not Employ Persons Guilty of Abuse: 7,288 • Drug Regimen is Free from Unnecessary Drugs: 7,040 • Dignity: 6,605
OIG Issues Compendium of Unimplemented Recommendations
from Dixon Health Care Solutions, Inc.
The Office of Inspector General issued is Compendium of Unimplemented Recommendations. It summarizes significant monetary and non monetary recommendations that, when implemented,will result in cost savings and / or improvements in program efficiency and effectiveness. This includes two unimplemented issues for home health agencies, three unimplemented issues for hospices, and an unimplemented issue for Recovery Audit Contractors. For more information please utilize the following link:
https://oig.hhs.gov/reports-and-publications/compendium/files/compendium2012.pdf
Avoiding Sexual Harassment by Residents
by Ted Boehm
A recent lawsuit filed by the U.S. Equal Employment Opportunity Commission (“EEOC”)against a healthcare facility in Virginia highlights a legal liability to which nursing homes and other long-term care facilities are particularly vulnerable: harassment of employees by residents.The lawsuit in question was filed under Title VII of the Civil Rights Act and it alleged that a female receptionist was subjected to a “sexually hostile work environment” on the basis of harassment by a resident. The lawsuit further alleged that the employee made numerous complaints to her supervisor about the harassment yet the employer failed to take proper corrective action.
Harassment Problems Specific to the Resident Care Arena
Sexual harassment is a difficult issue in any employment setting, but perhaps nowhere more sothan in the resident care arena. A number of different nursing home employees have regular,physical contact with non-employees – primarily the residents for whom they care (and the familymembers of those residents). Under Title VII, nursing home employees are protected fromharassment by residents just as they are from co-workers and supervisors. Hospitals, nursinghomes, assisted living facilities and other patient-care entities are responsible for providing aworkplace free of sexual harassment, regardless of whether the harassment is perpetrated by aco-worker or by a paying resident. Most nursing home employers have experienced episodes inwhich a resident acts out in an inappropriate manner. Often, the inappropriate behavior is due tothe resident having a deteriorated mental condition such as dementia or Alzheimer’s. As a resultof this condition, residents may not understand that their actions are inappropriate. However, thismental condition does not act to shield nursing home employers from liability.
How Employers Can Minimize the Risk of Harassment
Where sexual harassment has been alleged, a court will likely first look to whether the employerknew or should have known about the harassment and whether the employer did anything tocorrect the offending conduct. Of course a nursing home employer is somewhat constrained inhow it can respond to complaints of sexual harassment by residents. For example, a residentcannot be transferred unless the transfer complies with the Bill of Rights for Residents ofLong-Term Care Facilities. However, this constraint does not mean an employer should donothing. While it may not be possible to completely prevent harassment in the long-term caresetting due to the mental conditions of residents, employers can take steps to address andminimize the risk. First, employers should maintain a policy that addresses harassment byresidents or other third parties. The policy should specifically address how employees can reportthe harassment when it occurs. Maintaining a “reporting” policy is critical for another reasonbecause it provides employers with important legal defenses in situations involving allegedharassment by a supervisor. Second, employers should regularly train its employees on how toreact when they are harassed by a resident. Because the duties of a nursing home employee oftenrequire him or her to work in close contact with residents, there is an increased potential forharassment. If employees are trained to react properly and promptly, the unwelcome conduct maybe stopped before it becomes “severe or pervasive” – the standard used by courts in analyzingsexual harassment claims. Third, employers must respond to complaints appropriately. While theresponse will depend on the circumstances of the complaint, there are several “best practices”that employers should consider. For example, employers could make staffing adjustments so thatthe employee does not care for the resident by his or herself. Other options include assigning theresident to another employee’s care or discussing with the employee whether he or she wants totransfer to another part of the facility.
Respond to Complaints – But Do Not Retaliate
While it is critical for an employer to respond meaningfully to a complaint, it is just as importantthat the response does nothing to permit an employee to argue that he or she was retaliatedagainst for making the complaint. Retaliation claims have increased within all industries in recentyears and the long-term care industry is no exception. An employer should not take any actionthat is “materially adverse” to the employee -such as transferring the employee to a position thathas more onerous job duties. The most effective way to minimize the risk of harassment in yourlong term care facility is to conduct regular training on your policies or to implement policiesnow if they do not exist.
Why Long-Term Care Facilities Need to Embrace Change David Rubenstein, a speaker at the marcus evans Long-Term Care CXO Summit Spring 2013, on how long-termcare facilities need to move along with the industry. Interview with: David Rubenstein, Chief Operating Officer, AdCare Health Systems “Do not be static,” is the message that David Rubenstein, Chief Operating Officer at AdCareHealth Systems wanted to convey to long-term care (LTC) facility directors. The healthcareindustry is changing, and facilities have to embrace that to take advantage of businessopportunities, he commented. Ahead of the marcus evans Long-Term Care CXO Summit Spring 2013, in Los Angeles,California, January 28-29, Rubenstein exchanges his ideas on ensuring a LTC facility is patientcentered and evolving with the industry. Q: How can LTC facilities build a person-centered culture? DR: It is important to remember that we do not make products in this industry, but take care ofpeople. A lot of facilities get wrapped up in numbers, rules and regulations, but at the end of theday, our job is to take care of people. I always encourage management to walk the floors of theirfacility every morning before they go to their office and start dealing with all the technical issues,to keep that person-centered focus. Q: How is culture change best done? What do employees resist the most and what is the wayaround it? DR: Most people get into a rhythm of doing things the way they have always done. The problemis that the healthcare industry is constantly changing, whether it is the regulations, referralsources or the types of residents we admit. The facilities that do not embrace change are thosethat typically end up having problems or cannot achieve their goals. They will not achieve themif they do things the way they did ten years ago. LTC facilities need to be ahead of the curve. Weencourage folks to adapt their policies and procedures, so things are not static. For employees to embrace change, the leaders must spend a lot of time communicating andexplaining the game plan. Too often they send out budgets or expectations, without explainingthe rationale behind them. Q: How could LTC facilities be more profitable? What opportunities can they capitalize on at themoment? DR: Each facility needs to assess every department, expenditure, and resident before they comein. The margins in this business are not so large that they can overlook some expenses.Establishing par levels and expectations for supplies and commodities, such as food, could proveeffective. There is also value in outsourcing certain services, housekeeping and laundry forexample, to specialists who can do a better job. It is important to be as efficient as possible on the expense side, and to ensure that the facility isable to attract residents. Q: How will President Obama’s re-election impact the LTC industry? DR: All aspects of healthcare are going to be affected. The nursing home industry is the smallestsector of the healthcare budget, and we have gone through some radical adjustments in theMedicare payment rates over the last few years. We need to meet with our state leaders andlobbying groups to make sure they understand that right now a nursing home is the lowest costalternative for a patient who needs the services we provide. Interview by: Sarin Kouyoumdjian-Gurunlian, Press Manager, marcus evans, Summits Division About the Long-Term Care CXO Summit Spring 2013 This unique forum will take place at the Westin Long Beach, Los Angeles, California, January28-29, 2013. Offering much more than any conference, exhibition or trade show, this exclusivemeeting will bring together esteemed industry thought leaders and solution providers to a highlyfocused and interactive networking event. The Summit includes presentations on AccountableCare Organizations, reimbursement maximization, staff recruitment and retention, and electronicmedical record implementation. For more information please email d.drey@marcusevansch.com, or alternatively, feel free to call416-800-2481.
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