South Carolina Nursing Home Blog : South Carolina Nursing Home Lawyer & Attorney : Poliakoff & Associates Law Firm : Elderly Care, Senior Care

Huffington Post had a great article about the Bounce-Back Effect and how acute care hospitals and nursing homes manipulate Medicare policy to increase profits.  There is a new phenomenon that has the interest of both the government and hospitals. Patients who bounce back. This refers to patients who are discharged from an acute care hospital and are readmitted within 30 days.

Patient re-admissions or bounce back is a serious financial and quality issue. A 2009 study published in the New England Journal of Medicine analyzed almost 12 million Medicare beneficiaries and found that approximately one-fifth were readmitted within 30 days of discharge and an even more alarming 34 percent were admitted in 90 days. If we look a year out from discharge they reported 67.1 percent who had been discharged for a medical condition had been readmitted or had died.

This revolving door is expensive and cost Medicare $17.4 billion dollars in 2004.  As a result, Medicare has already started to collect data on all hospitals and will keep a three-year running average of their readmission rates. Those hospitals having high rates will be financially penalized.  Some studies calculate 75 percent of re-admissions are preventable.   A study in the Journal of the American Geriatric Society noted a "greater risk of multiple complicated transitions (bounce back) in patients initially discharged to skilled nursing facilities" and "a lower risk of multiple complicated transitions for patients initially discharged to rehabilitation facilities."

Communication, or the lack thereof, appears to be the major factor for patient bounce back. One study interviewed acute care hospitals and the Skilled Nursing Facilities (SNFs) where they sent patients. Each blamed the other for not providing adequate information. Complete lists of medications were missing. Follow-up appointments were never made or communicated. Wound care or other instructions were confusing or never received. There was no official hand-off from one physician to another.

Certain patients are at a particularly high risk to end up back in the hospital within 30 days. You are more likely to end up in the hospital if you:

-Are older
-Are African American
-Are on Medicaid
-Are discharged to a Skilled Nursing Facility (SNF)

The data suggests that the first three have less access to follow-up and primary care. Discharge to a Skilled Nursing Facility -- what used to be called a nursing home -- is particularly worrisome. Medicare spent $21 billion dollars on Skilled Nursing Facilities, approximately one half of all of the dollars spent on post-acute care ( SNF, home health, rehabilitation facilities, skilled nursing facilities and long-term care).

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Health Leaders Media and the blog Free Market Mojo wrote interesting articles about how Medicare policies increase hospice stays.  The Medicare hospice benefit is designed to provide visits by an interdisciplinary care team to better manage pain and other end of life issues and to provide psychosocial and spiritual support in the nursing home setting for residents and their families.

However, the length of an average Medicare-certified hospice stay in a nursing home has doubled during the last decade, researchers at Brown University have found.  Published in the August Journal of the American Geriatrics Society, their study finds that standard treatment time in nursing homes between 1999 and 2006 has increased from 46 to 93 days.   The study proves that nursing homes make more money by placing a resident on hospice because the standard daily payment rate for most Medicare hospice enrollment acts as an incentive for extended stays.

The study also found that the doubling of Medicare services in nursing homes is related to a 50% growth rate in the number of hospices—primarily for profit hospices.  Stays were longest in states with the greatest provider growth.  At the current time, a third of Medicare beneficiaries who die in nursing homes are accessing hospice services, and the study predicts that this number is expected to increase.

In addition to changing the rates of payment to reflect the proper timing of the more intense care needs, the researchers agree with a Medicare Payment Advisory Commission's recommendation that procedures for determining hospice eligibility recertification should be strengthened.

These changes would help the Medicare system avoid the possible scrutiny of nursing home residents who live beyond the physician certified six month prognosis—a Medicare requirement for hospice eligibility—and would permit patients to access the hospice care when they actually need it. 

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Several media outlets have reported the $16 million settlement between Maryland and the nursing home industry including Consumer Affairs, The Baltimore Sun and the Washington Post.  Nursing homes sued Maryland for more money.  The average monthyl rate Medicaid pays for nursing home care is over $6,000.  The class action lawsuit, filed in August 2005, claimed that the state's Department of Health and Mental Hygiene erroneously concluded that nursing home residents could afford co-payments for their care. That determination failed to take into account the debt that patients accrued while waiting to be approved for Medicaid coverage, according to the suit. Federal and state law requires states to consider patients' debt when calculating their income.

Maryland taxpayers will provide $8 million of the settlement funds, with the federal government paying the other half. Nursing homes claimed that the state owed $64 million for incorrect calculations made since 2002.

The settlement could serve as precedent for other states that fail to take patients' old debt into account when determining their Medicaid eligibility. In order to qualify for Medicaid, the federal-state program for the poor, an individual must deplete his or her assets to reach a $2,000 threshold. Often, that patient needs care before reaching that limit and can accumulate thousands of dollars in nursing home bills.

Consumers can obtain information at the official settlement website

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The Tennessean had an article about the arrest of Regina Jacobs.  The nursing home employee is charged with stealing more than $400,000 from the nursing home where she
worked for more than 10 years. I wonder how long it was going on?  How could she be so greedy?

Officers with the Tennessee Bureau of Investigation arrested her after she was indicted by the Wilson County grand jury on three counts of theft over $60,000, two counts of theft over $10,000 and one count of theft over $1,000.

In December 2008, the nursing home, Quality Care Health Center, finally discovered that Jacobs, a business office manager, had been cashing checks intended to cover patient costs and keeping the money.  An internal investigation and audit at the nursing home revealed that about 70 patients' accounts had been affected.

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The Wall Street journal had an interesting article about Omnicare's legal troubles.  Mr. Gemunder's was CEO of Covington, Ky.-based Omnicare, the nation's largest dispenser of pharmaceuticals to nursing homes serving 1.4 million beds in 47 states.  Obviously, Omnicare gets its profits from Medicare, Medicaid and health insurance.

Mr. Gemunder had been in charge since 1981, but recently retired with a large lump-sum pension payout.  He's getting a $91 million pension payout, plus severance, vesting of restricted stock  that bring his final payday to at least $130 million. And that's on top of the $14 million he bagged last year.

And what did the shareholders get for their money? Omnicare shares took a tumble last week after the company reported a shocking drop in the number of prescriptions it fills.

And what did the taxpayers and customers get? Omnicare has litigation costs amid evidence of kickback and billing schemes.  For example, in November 2009, Omnicare announced it would pay $98 million to settle a civil case brought by the Justice Department that it paid kickbacks to nursing homes and took kickbacks from pharmaceutical companies, including Johnson & Johnson. Omnicare also agreed to pay $49.5 million in 2006 to settle Medicare fraud claims. And last month, new details emerged in a continuing kickback lawsuit in Illinois.

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The Centers for Medicare & Medicaid Services posted payment updates for skilled nursing and inpatient rehabilitation facilities' prospective payment systems for fiscal 2011. Nursing homes will realize a 1.7% increase in its market basket rate.  The nursing home increase was actually 2.3%, but federal regulators noted that an automatic click down of 0.6% was put into effect because overpayments were made at that rate in fiscal 2009. The net nationwide gain in Medicare payments to skilled nursing facilities will be $542 million in fiscal 2011.

CMS would be putting MDS 3.0 into effect on Oct. 1, which will modify resident assessment tool. As previously indicated, the RUGs-IV refined payment system will begin at the same time but will be recalibrated in the future, after CMS devises an appropriate way to recalibrate payments.

The SNF and IRF payment updates for fiscal 2011 will be officially published in the Federal Register. 

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The Chicago Tribune had an article about new details in the OmniCare kickback scheme that included many of the country's for profit nursing home chains.  Omnicare — which supplies medicine to roughly 1.4 million nursing home residents in facilities across the U.S. and enjoys an 85 percent share of this market.  Court documents add new details to a whistle-blower lawsuit alleging that the giant pharmaceutical firm Omnicare Inc. paid kickbacks to Illinois' most prominent nursing home families.

The new filing, which contains 164 pages of internal company records and other documents, is intended to bolster pending civil allegations that Omnicare significantly inflated the purchase price it paid in 2004 for a pharmacy company purportedly controlled by Chicago nursing home operators Philip Esformes and his father, Morris Esformes.

Omnicare's $32 million purchase of that company, Total Pharmacy, included roughly $16 million that was a kickback to secure long-term pharmacy contracts with nearly three dozen nursing homes the Esformeses operated or controlled

The new documents include copies of handwritten notes from a March 2004 meeting at Morris Esformes' Lincolnwood headquarters between Omnicare CEO Joel Gemunder and Morris Esformes to discuss the sale of Total Pharmacy to Omnicare.   Gemunder offered to pay $15 million for Total Pharmacy if three-year contracts were in place with Esformes-controlled homes, $20 million if there were five-year contracts and $25 million if there were 10-year contracts. In the final sale, Omnicare paid the $25 million and let Total Pharmacy keep $7 million worth of accounts receivable, making the sale worth $32 million.

The new court filing also includes other handwritten notes taken two days after the meeting that allegedly show Morris Esformes agreed to backdate nursing home pharmacy contracts "in order to avoid the appearance of impropriety," according to the lawsuit.

Philip and Morris Esformes, who are listed as part-owners of 28 nursing homes in Illinois and Florida, and had ties to others in Missouri, have not been charged with any crime in the sale of Total Pharmacy.

The whitsle blowers include two industry insiders: pharmacy executive Maureen Nehls, who served as vice president of pharmacy operations for Total Pharmacy, and former health care dealmaker Adam Resnick, a consultant to Total Pharmacy at the time of the sale.

The Tribune in April reported that the Esformeses were embroiled in what prosecutors called a "horrific" patient-brokering scheme in which unsuspecting nursing home residents were shuttled to and from a local psychiatric hospital for unnecessary treatments. 

Government authorities in Boston have won settlements in federal court based on Resnick's information about other deals involving Omnicare and separate East Coast nursing home chains including Mariner and SavaSeniorCare owned and operated ath time by Murray Forman and Leonard Grunstein.

The False Claims Act allows private citizens to file lawsuits against companies and individuals defrauding the government and recover funds on the government's behalf.

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I ran across a couple of articles on Crystal Rader.  Born with muscular dystrophy, Rader requires a motorized wheelchair to get around.  Rader enjoys leaving the nursing home for activities and the wheelchair is the only way she can participate.  Her current wheelchair is six years old and ready to break down.   Rader bought it for $35,000 (with assistance of Medicaid) six years ago,

She applied to Colorado's Medicaid program for assistance for a new wheelchair. Medicaid denied her request, claiming in its rejection letter that the wheelchair is unavailable to her under the state's Durable Medical Equipment Program because she lives at the Fort Collins Health Care Center, a nursing home owned and operated by Sava Senior Care, therefore, the nursing home should provide the wheelchair and then presumably get reimbursed by Medicaid later.

"If they live in a long-term care or nursing facility, we do not pay for durable medical equipment unless that person is within 14 days of discharge," Department of Health Care Policy and Financing spokeswoman Joanne Lindsey said.   The state pays the Fort Collins Health Care Center for medical and equipment costs.

Rader said she isn't confident the Fort Collins Health Care Center, which is owned by Atlanta-based Sava Senior Care, will help her get a new chair.

"For a 26-year-old to be stuck in bed is horrible," Rader said. "It scares me. I lose all my activities I like to do."

I wonder why the local Ombudsman isn't involved?
A fund has been set up to help Crystal Rader replace her aging motorized wheelchair. 

See articles from the Coloradoan here and here.

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Joanna Weiss of the Boston Globe wrote a great article on Medicare and waste. Below is excerpts of the article which is based on her experience with a relative on Medicare.  One axiom of our Medicare system: It’s hard to understand how maddening it is until something happens to your family.

Take, for example, my own elderly relative, who recently spent time in the hospital. Everyone wanted him to recover at home, but we knew that would require nursing care. And his care coordinator in the hospital had strange, bad news: If he went to a residential nursing home, Medicare would foot the bill. But if he wanted an at-home nurse, at substantially less cost, Medicare would only cover a few hours of care, a few days a week.

To anyone with a smidge of common sense, that sounds absurd. But when I relayed the story to Dr. Brent James, he wasn’t surprised. As chief quality officer at Intermountain Healthcare, a network of hospitals and providers in Utah, he’s an expert in Medicare’s one-size-fits-all solutions and perverse incentives. More than a decade ago, his hospitals put a reform in place, involving the timing of antibiotics, that helped patients recover more quickly and completely. But the hospitals were losing millions of dollars, and the billing records solved the mystery. If a patient got pneumonia and went on a ventilator, the reimbursement from Medicare was $800 more than the treatment itself. If that same patient didn’t get pneumonia, the billing codes changed, and the payment for his briefer, simpler hospital stay was $800 less than the cost.

James has implemented many solutions at Intermountain. Among them are “global payments,’’ which opponents have managed to demonize as rationing of care. As James explained it to me, it’s a far-less-nefarious way to create the the right incentives in a system that now often has the wrong ones.

In the case of my elderly relative, Medicare would give his hospital a set amount of money to coordinate and spend. Any money left over would be profit. If the payment fell short of the cost of his care, the hospital would eat the loss.

In theory, that could give doctors and nurses a reason to provide him with less care. Careful monitoring of quality would have to go hand in hand with global payments. But this change could also encourage steps known to reduce the length and cost of illnesses. Washing hands more often to reduce the spread of infection. Coordinating better among hospital divisions. Offering better access to the home-based nursing care that would cost a lot less.

“Over 50 percent of expenditures on a patient on health care are technically waste,’’ James told me. But “one person’s waste is another person’s income is a major political contribution.’’

According to some health care and economics experts — including Roger Feldman and Bryan Dowd at the University of Minnesota and Bob Coulam at Simmons College, who wrote a recent paper on the subject — competitive pricing would shave 8 percent off the annual Medicare budget. That amounts to $50 billion to $60 billion every year. And yet, every time that reform has been proposed, providers have revolted, and Congress has blocked it in a very bipartisan way.

Now we have a looming crisis, a foreseeable future when the Medicare Part A trust fund will go bankrupt, or when Medicare costs will start to overwhelm the federal budget. There will come a point when ignoring the problem won’t be feasible anymore. Maybe it will happen too late to help some of my own relatives. But when it does happen, there’s some small comfort in knowing that solutions are out there — just waiting for action, a little bit of courage, and a will to change.
 

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Karen Mason was the chief executive officer of Havenwood Nursing and Rehabilitation Center who has been sentenced to two years in prison for tax evasion. Federal prosecutors say 57-year-old Karen Mason, previously known as Karen Mueller, admitted taking more than $1 million from the Havenwood Nursing and Rehabilitation Center from 2002 through 2005 and not reporting the money as income.

The U.S. attorney's office says she used the money for jewelry, home furnishings, cars, entertainment, travel and other expenses, including more than $30,000 for a wedding and honeymoon for one of her children. It says she underpaid her federal income taxes by more than $360,000.

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