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

As healthcare organizations receive increasing pressure to lower infection rates in patients, OSHA is investigating ways to keep healthcare workers safe from infectious exposures. The public is aware of the numerous studies last year that confirmed the presence of high amounts of bacteria on healthcare worker uniforms.  A new study addresses these issues appears in the March, 2012 issue of the Journal Infection Control and Hospital Epidemiology.

According to the research, Vestex® fluid barrier / antimicrobial scrubs had “a statistically significant, 4-7 log Colony forming unit (CFU) decrease in the overall mean log CFU MRSA count compared to normal scrubs.” This means there was greater than a 99.99% reduction in the amount of the superbug MRSA on the Vestex uniforms, as compared to regular scrub uniforms.

Disclaimer

The ability of Vestex®to reduce MRSA or other microbial bioburden on garments has not been shown to correlate with any clinical event or to be able to reduce patient infections. Clinical studies to evaluate reduction in infection have not been performed. The antimicrobial agent used in Vestex® is EPA registered to guard against the degradation of the fabric from microorganisms and to retard the growth and action of odor causing bacteria.

Many states are placing the financial burden of caring for seniors with Alzheimer's from Medicaid to families.  But the shift will create new needs - additional support services for family caregivers, more home health workers, and new technologies and treatments to slow the disease's relentless advance.  Such services keep seniors healthier longer and give caregivers - often spouses or adult children - a much-needed break. Alzheimer's, a form of dementia, is a progressive disorder that, over time, strips away memory, judgment, language and the ability to perform the most basic tasks.

5.4 million Americans are diagnosed with Alzheimer's, which affects 13 percent of adults 65 and older. Cost of their care runs $172 billion a year, including about $34 billion in state and federal Medicaid funds.

By 2050, the Alzheimer's Association projects, about 16 million Americans - 16 percent of adults 65 and older - will have the disease. The numbers are rising because Americans are living longer and being diagnosed more accurately. But the cost of this care also will rise - topping $1 trillion annually. 

Alzheimer's is the nation's sixth-leading cause of death. While deaths from cancer, heart disease, stroke and other major killers have declined over the last decade, deaths from Alzheimer's increased 66 percent from 2000 to 2008.

 For people who don't require nursing home care, adult day programs help people in the early stages of dementia remain active for as long as possible.

The real hope is that someone will find a treatment that stops the disease in its tracks early or slows it down.   Source Cincinnati Community Press.

The Palm Beach Post and the Highlands Today had articles about Florida Republicans refusing to accept $35.7 million in a federal grant to help move nursing-home residents to community-based services.  Why would they refuse federal money unless they were trying to protect nursing home profits?

Senate Minority Leader Nan Rich, D-Weston said serving people outside of costly nursing homes would save money for the state.  The AARP also blasted the move in a statement issued:

"This would not only have been less expensive for taxpayers, it would have helped people with mental or physical disabilities get out or stay out of nursing homes and remain where they want to be — in their homes," said Jack McRay, the organization's advocacy manager. "It also would have kept tax dollars paid by Florida taxpayers in Florida — rather than having them spent in other states."

Florida is one of 13 states that were awarded a federal demonstration grant for the program. The money comes from the new federal health care law.

CNN Money had an article about the epidemic of "dumping" and how budget cuts will increase this tragic problem.  For the elderly, state budget cuts could mean losing their beds at the nursing home. Here's a look at what's at risk for many of the nation's elderly.

Shuttering nursing homes
Among the most dramatic of the proposed cuts is the severe reduction in Medicaid reimbursement rates to nursing homes in Texas. Facing a shortfall of up to $27 billion, state lawmakers want to reduce the rate by 10%. But payments to nursing homes would plummet by a total of 34% because they would also lose federal matching funds.  This would result in the closing of 850 of the state's 1,000 nursing homes, forcing up to 45,000 elderly residents to find other accommodations, said David Thomason, chair of the Texas Senior Advocacy Coalition.

Losing their center
If New York State does not restore $27 million in funding for New York City's senior centers. Without this money, Mayor Michael Bloomberg has said he'll have to close 105 of the city's 256 centers.  Most center's services are critical to keeping senior citizens living at home, said David Gillcrist, executive director of Project Find.  They receive a nutritious meal and take classes that improve their balance, strength and confidence. Equally as important, they are able to socialize with friends and not become isolated and depressed.

Meals on Wheels saved for now
Senior services agencies in Georgia looked like they'd lose a million dollars of funding for Meals on Wheels. Agencies prepared to stop feeding a total of 138,000 elderly residents. Georgia reduced its support for Meals on Wheels in 2009, supplanting it with $1 million in federal stimulus money. That federal funding is running out this year. Gov. Nathan Deal did not replace it with state money.

Lawmakers agreed that the program was too important to gut. The state Assembly restored the funding in early March by cutting some other contracts in the budget, and the Senate is expected to follow suit soon.

WSPA reported that Michael Morgan was arrested on two counts of first degree assault and battery for fondling two residents at Magnolia Manor in Greenville.  Police say this isn't the first time the nursing home has had the same kind of complaints about the same man.  "News Channel 7 also learned that residents complained of the same types of assaults several weeks ago, and a police report was filed then. Investigators say the suspect description matched that of Morgan."  He has now been accused of molesting five people at Magnolia Manor.  Greenville police say there were three female and two male victims of the attacks March 17 and Feb. 25.

Magnolia Manor is owned by Fundamental Long Term Care Holdings LLC out of Sparks, Md.   The facility has contracts with Fundamental Administrative Services LLC and Fundamental Clinical Consulting LLC which are also owned by Fundamental Long Term Care Holdings LLC.  Fundamental is owned by Murray Forman and Leonard Grunstein.

No one knows how the man got into the nursing home undetected or why the residents were not being supervised to prevent the assault.   Sgt. Jason Rampey says Morgan worked for a company that provides services to nursing homes. 

From the Consumer Voice website:
The Consumer Voice staff were pleased to attend the Senate Special Committee on Aging's hearing yesterday focusing on elder abuse, neglect and financial exploitation. The hearing was hosted by Chairman Herb Kohl (D-WI) and Ranking Member Bob Corker (R-TN), and the following witnesses provided testimony:

Mickey Rooney, Actor, elder abuse victim and advocate
Kay Brown, Director, Education, Workforce and Income Security, Government Accountability Office
Kathleen Quinn, National Adult Protective Services Association [NAPSA]
Mark Lachs, MD, MPH, Weill College of Cornell University
Bonnie Brandl, Wisconsin Coalition Against Domestic Violence, National Clearinghouse on Abuse Later in Life [NCALL]
Marie-Therese Connolly, Life Long Justice [LLJ] (MT received the Consumer Voice 2010 Policy Leadership Award.)
 

Mickey Rooney's testimony focused on the prevalence of elder abuse as he recounted his recent struggle with financial abuse by a close relative. He encouraged Congress to pass a law protecting seniors from all types of abuse whether emotional, physical or financial. Not only did Mr. Rooney provide a call to action for Congress, he also encouraged victims of elder abuse to come forward and tell their stories to end the cycle of abuse.

The second panel of witnesses consisted of experts in the field of elder abuse. In her testimony, Kay Brown discussed the findings of the new GAO report, Elder Justice: Stronger Federal Leadership Could Enhance National Response to Elder Abuse. Ms. Brown's testimony highlighted the challenges to Adult Protective Services programs across the country and the limited federal actions to address this issue. She encouraged HHS to establish a national data system whereby APS programs could share information and data that would improve performance across the country.

Kathleen Quinn's testimony included startling information about APS programs struggling to provide basic services to the elderly due to an increase in caseload and a decrease in state funding. She suggested building a national infrastructure much like Kay Brown mentioned, but also including a national resource center to provide training and tools to state programs to increase their capacity.

Dr. Mark Lachs highlighted his own research in his testimony, which included data on the number of missed cases of elder abuse - for every one case of abuse identified, there are 24 missed cases. He suggested the use of multi-disciplinary elder abuse teams to coordinate the care for the individual while also being cost-efficient. Senator Ron Wyden (D-OR) likened this approach to the "elder abuse equivalent of a medical home".

Bonnie Brandl began her testimony by providing an example of financial abuse in her home state of Wisconsin. She went on to outline the factors leading to a rise in elder abuse, including decreased resources, lack of training for providers, and low levels of collaboration within communities. Her suggestion was to increase the Abuse in Later Life Program created by the Violence Against Women Act, noting that within this program, providers receive extensive training as well as cross training to provide a sense of collaboration.

Finally, Marie-Therese Connolly stressed in her testimony the increased costs associated with elder abuse. These increased costs occur when an elderly person endures financial abuse resulting in a loss of their assets, ultimately forcing them to enroll in public programs like Medicaid. Although the total cost is unknown, Ms. Connolly highlighted the need for additional research to determine not only the cost, but what methods are most effective in helping these individuals in their times of need.

Overall, the witnesses painted a picture of the stark realities of elder abuse burdening the United States and recommended stronger federal leadership in Congress and the administration, along with additional research, as ways to address the problem.

Senator Kohl also announced that he, along with other members of the Committee, was introducing legislation to address elder abuse.

A webcast of the hearing is available on the Committee's website.

 

The New York Times' Blog called The New Old Age had an informative discussion on Medicare reimbursement and overpayment.  Facilities operated for profit are far more likely to classify patients as needing the highest levels of care, and therefore to collect the biggest payments from Medicare, than nonprofits, according to a recent report by the inspector general’s office of the Department of Health and Human Services. Tellingly titled “Questionable Billing by Skilled Nursing Facilities,” the government study looked into how often nursing homes seek reimbursement for the costliest levels of care and found a huge increase in just two years.

In Medicare, people receiving benefits in nursing homes after a hospitalization (the only way Part A pays for nursing homes) are slotted into categories called resource utilization groups, or R.U.G.’s. Which group the beneficiaries fall into depends on how much therapy they receive and how many activities of daily living they need help with. The higher the classification, the more Medicare pays.

From 2006 to 2008, the inspector general’s office discovered, the proportion of patients classified in the highest therapy groups jumped to 28 percent from 17 percent, costing an additional $5 billion. And for-profit nursing homes, which constitute more than two-thirds of the nation’s nursing homes, were strikingly more apt to seek the highest reimbursement, the report found. Almost a third of their patients were in the highest R.U.G.’s, compared with 18 percent in nonprofit homes and 13 percent in government facilities. For-profit facilities also kept patients substantially longer, 29 days versus 23 at nonprofit homes.

Moreover, among the for-profits, the large chains were the most likely to charge for patients in the highest care categories and to extend their stays.

“These billing patterns indicate that certain [skilled nursing facilities] may be routinely placing beneficiaries into higher paying R.U.G.’s” — regardless of how much care they need — “or keeping beneficiaries in Part A stays longer than necessary,” the report concluded. Unnecessary treatments and therapies can harm patients, not just the Medicare budget, the report noted.

The inspector general’s office, continuing its review, made several recommendations (stronger monitoring, for instance) that the Centers for Medicare and Medicaid Services have accepted, and the office also referred the 348 worst offenders to Medicare officials for action.

“It’s consistent. The for-profits have the worst staffing ratios and poorer quality based on the number of deficiencies — violations of federal requirements — and the most serious deficiencies,” said Charlene Harrington, professor emeritus of social and behavioral sciences at the University of California, San Francisco, who has led a lot of that research.

In a new study, not yet published, Dr. Harrington also has found that of all forms of ownership, homes owned by the 10 largest chains fared worse than other for-profits. “These facilities are reporting the highest acuity levels” — meaning the most serious conditions for patients — “and the worst staffing,” she told me. “Facilities are supposed to increase their staffs when people are sicker.”

The Associated Press had an interesting article about the nursing home industry's attempt to recruit younger residents.  For decades, the mission at Miami Jewish Home and Hospital was simple: To care for the old. But like nursing homes around the country, the facility is changing how it does business because of consumer demands and the economic realities of selling a service nearly no one wants.  "This is a place of life. This isn't a place of impending death," said Blaise Mercadante, chief marketing officer at Miami Jewish. "And that's fundamentally the mindset change."

"Nursing homes are waking up more and more to the reality that their old model of doing business is not going to hold up in the 21st century," said Elinor Ginzler, an expert on long-term care at AARP.

Even as the number of older Americans surges with the aging of the massive baby boom generation, demand for nursing homes is decreasing. The Centers for Disease Control and Prevention estimate that the number of nursing home residents fell from 1.63 million in 1999 to 1.49 million in 2004, the last year for which data is available. Meanwhile, the number of nursing homes decreased by nearly 16 percent over the two decades ending in 2004.

Demand for services like assisted living, in-home care and adult day care, meanwhile, is booming. Nursing homes have expanded their offerings to cope with shortfalls after finding that in many cases they cannot make enough profit Medicaid, the main governmental provider of long-term care.

Brian Williamson, an analyst for Standard & Poor's who follows nursing homes, said facilities have been branching out to deal with lower occupancy rates. "Where before you may have been able to keep your facility 97 percent full, now maybe it's 92 percent," he said. "You have to figure out how do I compensate for that lost percentage of beds."

Neil Kurtz, CEO of Golden Living, one of the largest nursing home operators in the U.S., said the emphasis has shifted from providing a place where seniors can grow old and die, to a place where seniors can recover from illness or surgery before moving back home or elsewhere.

Other companies whose core business has been caring for the elderly are also coming up with new ways to make money, but Miami Jewish has taken the innovation further than most. While similar providers have expanded senior-related offerings like in-home care or assisted living, the South Florida home took a gamble in recent years by hiring specialists in fields that attract younger patients. 

Another provider that's changed its mix of services is Ecumen, which operates 70 senior communities in Minnesota, Wisconsin, Iowa, North Dakota and Idaho. In 2004, Ecumen derived more than 80 percent of its $99 million in revenues from traditional nursing homes. Five years later, revenues climbed to $126 million while nursing homes' share fell to less than 60 percent, as Ecumen markedly expanded assisted living complexes that allow seniors to be more independent. A $2.5 million loss in 2005 became a $937,000 profit last year.

At Miami Jewish, the broadening of services began when its executives' saw a market for services such as pain management and biofeedback, which uses electrodes to increase mobility in paralyzed limbs. The hospital built a staff of experts in those areas mostly from scratch, adding more than 50 specialists to staff its pain, biofeedback and rehabilitation centers.

NY Times had an article about cuts in home-care services for elderly and disabled because of budget shortfalls despite the fact that programs have been shown to save states money in the long run because they keep people out of nursing homes.

Since the start of the recession, at least 25 states and the District of Columbia have curtailed programs that include meal deliveries, housekeeping aid and assistance for family caregivers, according to the Center on Budget and Policy Priorities, a research organization. That threatens to reverse a long-term trend of enabling people to stay in their homes longer.

States that have made cuts:

Oregon, facing a $577 million deficit, was cutting home aides to more than 4,500 low-income residents.  State legislators say home care is a service the state can no longer afford. Cuts affecting an additional 10,500 people are scheduled for Oct. 1.

¶Florida placed 69,000 people on waiting lists for home or community services last year, and more than 5,700 of them ended up in Medicaid nursing homes.

¶Alabama cut housekeeping services — useful for people who can no longer do some cleaning tasks — for more than 1,000 elderly residents.

¶Arizona sliced independent living supports and respite programs for family caregivers.

¶Kansas, with a $131 million shortfall, will cut independent-living services for 2,800 people with disabilities in the next year.

In Illinois, providers of Meals on Wheels have stopped adding clients because the state was not reimbursing them.

Colorado, Mississippi, Missouri, Nevada, New Jersey, New York and Texas have all made cuts or frozen spending at a time when the elderly population — and the need for services — is growing.

In California, which faces a budget shortfall of $19.1 billion for the 2010-11 fiscal year, Gov. Arnold Schwarzenegger’s office proposed eliminating adult day health care centers that serve 45,000 people and in-home supportive services that help more than 400,000 elderly, disabled or blind residents.

Because Medicaid regulations require states to provide nursing home care to receive federal Medicaid money, legislators often have more leeway to cut from home services. Advocates for the elderly and the disabled worry that these cuts are just the beginning, because state ledgers tend to recover more slowly than the national economy.

Barbara Quirk wrote an article on The Cap Times regarding certain aspects of the Affordable Care Act.  The federal Department of Health and Human Services announced the availability of $60 million in Affordable Care Act grants to help people navigate their health and long-term care options. Through these grants, HHS’s Administration on Aging will collaborate with the Centers for Medicare and Medicaid (CMS) to encourage an integrated approach to health care and social services. It is a model that has long been recognized as essential for patients and their caregivers.

“The Affordable Care Act seeks to lower health care costs, improve the quality of health care and, perhaps most importantly, give people more control over their own care. These new grants, authorized under the new law, will help seniors, individuals with disabilities and their families get better quality care and more control. We’ve also streamlined the process for states and people who rely on these funds,” said HHS Secretary Kathleen Sebelius.

“We know how difficult it can be for caregivers and patients to try and deal with a sudden illness or chronic disease while at the same time trying to negotiate through a complex health care system to figure where you can get help. These new funds that we have bundled together will help promote better opportunities for coordination of health and long-term supports,” said Sebelius.

“When it comes to long-term health care, each patient has a unique mix of complex medical and social needs that must be considered when seeking care,” says Marilyn Tavenner, acting CMS administrator. “Our health care system can offer many options to meeting those needs from traditional nursing home care to home and community-based services. Making patients and their families aware of these options will help them make inherently difficult decisions about long-term care. The integrated program will help families make informed choices and make sure patients have more control over their own care.”

This is part of a larger nationwide effort to bring direct-care workers into positions of respect and acknowledgment by giving the patients or the families a bigger voice in decisions about working conditions and wages. Whether in a traditional nursing home setting or an in-home setting, a critical factor is continuity of care.

Basic to any effort to improve long-term care is retaining, supporting and strengthening this core group of personal care providers.

Affordable Care Act funds will be available to states, area agencies on aging and Aging and Disability Resource Centers to coordinate and continue to encourage the use of tested Care Transitions Program models that integrate the medical and social service systems. This will smooth the transition of individuals from hospitals and nursing homes back to their communities and homes.

Barbara Quirk is a Madison geriatric nurse practitioner. Tandbquirk@aol.com
 

The Jackson Sun News had an incredible story about a nursing home who hired a woman with a long history of fraud and forgery.  Sheila Watson was arrested and charged with one count of identity theft, four counts of criminal simulation, four counts of forgery, one count of criminal impersonation and one count of theft over $1,000.  Watson was the social services director at Bells Nursing Home.  Watson is also an ex-convict who has used at least half a dozen different names in a long history of state and federal fraud, forgery and theft convictions.

The investigation into Watson — who has worked at the nursing home since July — began when the nursing home received a call from a state agency.  The investigation is still ongoing but "They said she did a great job and was a good employee," Klyce said. "We've looked at her computer and couldn't find any evidence at this point."

When the Sheriff's Department began investigating, authorities soon discovered Watson's job application was only the tip of the iceberg, he said:

She had borrowed money from the Bank of Crockett County using false documents. She was wanted in Iowa on charges of theft over $10,000. She was on probation but was using a different name and job description to report to her probation officer.

Watson was arrested as Sheila F. Hayes in November 2002 on federal charges of forgery, theft of property and identity theft, according to The Jackson Sun's archives.

She was accused of stealing mail from 135 victims in West and Middle Tennessee for the purpose of stealing identities and embezzling money. She later pleaded guilty to one count of mail theft and was sentenced to five years in prison and three years' probation.

At the time, the judge said Hayes had the highest criminal history score of any woman he had seen in his 20 years as a judge. The bulk of her prior convictions were for theft and fraud, but she was also convicted of escape from a Metro Nashville jail. Watson had charges stretching back to 1989, most of them in Middle and West Tennessee. She reported to a probation officer in Jackson under the name Sheila Hayes and told them she worked for a construction company.

Becker's ASC Review had an article about a three-week trial where a Detroit federal jury convicted Jose Castro-Ramirez, MD on 13 counts in connection with an $18.3 million Medicare fraud scheme.  Dr. Castro-Ramirez was convicted of one count of conspiracy to commit healthcare fraud, 11 counts of healthcare fraud and one count of conspiracy to launder the proceeds of the fraudulent scheme.

Beginning in 2003, the Detroit area physician entered into an agreement with Suresh Chand, a co-conspirator and owner of several companies based in Warren, Mich., that purportedly provided physical and occupational therapy services to Medicare beneficiaries.  In reality, Mr. Chand and his associates created false therapy files documenting physical and occupational therapy services to Medicare beneficiaries that had not occurred. The fictitious services were then billed to Medicare through fake providers controlled by Mr. Chand.

Mr. Chand and others paid kickbacks and provided other inducements to Medicare beneficiaries in exchange for their Medicare numbers and signatures showing they had received therapy services. Dr. Castro-Ramirez signed therapy prescriptions falsely indicating that he had evaluated the Medicare beneficiaries and recommended the therapy, when in fact, he had not overseen any treatment to the patients and was aware that he was participating in fraud.

Dr. Castro-Ramirez also wrote thousands of prescriptions for controlled substances including Vicodin and Xanax for patients he had never seen between 2003 and 2007, as part of Mr. Chand's recruitment of the Medicare beneficiaries.

Dr. Castro-Ramirez profited from the scheme by receiving proceeds from billings to Medicare for "home visits," many of which were never made, for beneficiaries Mr. Chand recruited. Mr. Chand also distributed proceeds directly to Dr. Castro-Ramirez through transactions intended to hide the origins and nature of the funds. Dr. Castsro-Ramirez submitted $1.4 million in claims to Medicare for the "home visits," $929,000 of which Medicare paid. Mr. Chand and his co-conspirators submitted claims to Medicare totaling $18.3 million for therapy services that were supposedly overseen by Dr. Castro-Ramirez but were never performed. Of these, Medicare paid $8.56 million.

Mr. Chand pleaded guilty in Sept. 2009 in U.S. District Court to one count of conspiracy to commit healthcare fraud and one count of conspiracy to launder money.

At a scheduled June sentencing, Dr. Castro-Ramirez faces a maximum penalty of 10 years in prison and a $250,000 fine for the healthcare fraud conspiracy and fraud counts, as well as a maximum penalty of 20 years in prison and a $250,000 fine on the money laundering conspiracy count.

Visiting Physicians Association will pay $9.5 million to settle for submitting false claims to Medicare, Medicaid and the military TRICARE medical program.  The doctors' group submitted false claims for unnecessary home visits, tests and procedures, as well as services that were never provided.   The claims were for people with Medicare, Medicaid and the military TRICARE insurance programs.   The settlement resolves four lawsuits filed by private plaintiffs under provisions of the False Claims Act, which permit private parties to file an action on the government’s behalf and share in any recovery. This settlement provides that the four whistle-blower plaintiffs will collectively receive a total of approximately $1.7 million.

Visiting Physicians Association, which has provided home health services in Michigan, Ohio, Georgia and Wisconsin, will make the payments to the U.S. government and the state of Michigan, to settle the allegations that it submitted claims for unnecessary home visits, unnecessary tests and procedures and other services it never provided.

The L.A. Times had an article discussing the recent fine imposed on a nursing home facility.   Lakewood Manor North Nursing Home has been fined $100,000 after state officials concluded that poor care led to the injury and death of an elderly resident who fell and hurt his head.

The case involved a resident who lost his balance and struck his head on a bed rail when he was being transferred from his bed to a wheelchair. State officials said the facility failed to provide adequate support for the resident as he was transferred to his wheelchair.

At 8:30 a.m., about half an hour after the blow to the head, nurses' notes documented the man had a bluish discoloration on the left side of his head. The attending physician was paged at 8:45 a.m. and 12:30 p.m., but the doctor did not return the call. His condition continued to deteriorate throughout the day; he refused lunch and dinner and complained of not feeling well.  At 8:30 p.m., he was observed as lethargic. Finally, at an unspecified time, an attending physician was reached, and the patient was transferred to a hospital at 9:30 p.m.—more than 13 hours after he had struck his head. The patient had suffered bleeding in the brain and died five days later.

Investigators said the licensed nurses should have called either an alternate physician or the medical director when the attending physician did not respond to pages, or call 911 in an emergency.

“Failure of the facility staff to immediately notify the physician and to provide the necessary care and services to Resident 1 [the patient] ... presented a substantial probability that serious harm would result, and did result to Resident 1 [the patient’s] death,” the report said.
 

A new report shows that Medicaid programs are failing to deliver adequate medical services to the low-income populations they were designed to serve including nursing home residents.  The non-profit consumer advocacy organization Public Citizen issued a report ranking Medicaid programs by how they met and surpassed federal mandates in four categories: eligibility, scope of services, quality of care and provider reimbursement.

Fifty-five million, mostly low-income Americans get their health care coverage through their state Medicaid program. The worst Medicaid programs in the country, according to Public Citizen, are those in Alabama, Colorado, Idaho, Indiana, Mississippi, Missouri, Oklahoma, South Carolina, South Dakota and Texas.

Public Citizen ranked states by the optional health care services that states provide beyond legally mandated services.
"Medicaid desperately needs nationwide uniform standards of quality of care and an effective means of monitoring and upholding those standards," said Ms. Ramirez de Arellano.

See story here

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