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CMA Alert – Improvement Standard Survey Results; Junk Plans Are Here; 3-Day Hospital Requirement Increases Costs; Who Really Owns SNF’s?

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  1. Middle for Medicare Advocacy Survey: CMS’ Jimmo v. Sebelius “Improvement Standard” Schooling Nonetheless Not Working
  2. Well being Care Sabotage: Expanded “Short-Term, Limited-Duration Insurance” is Right here
  3. Research: Three-Day Hospital Requirement for Publish-Hospital Care In a Expert Nursing Facility Increases Medicare Prices
  4. Who Owns Nursing Amenities and Why?

Middle for Medicare Advocacy Survey: CMS’ Jimmo v. Sebelius “Improvement Standard” Schooling Nonetheless Not Working

The Middle for Medicare Advocacy just lately accomplished a survey of Jimmo v. Sebelius stakeholders to research the effectiveness of the Facilities for Medicare & Medicaid Providers’ schooling efforts relating to the Jimmo Settlement, which clarified that Medicare should cowl expert upkeep care within the residence well being, expert nursing facility and outpatient remedy settings. Sadly, the outcomes weren’t encouraging.

The survey was despatched to over 400 suppliers and advocates throughout a number of disciplines. There was a few 20% response fee. Of these respondents, virtually 40% nonetheless had not heard concerning the Jimmo Settlement, and virtually 30% remained unaware that Medicare protection depends upon the necessity for expert care, no matter a beneficiary’s potential for enchancment, and that Medicare covers expert care to take care of a situation or sluggish deterioration.

Most tellingly, over 70% of respondents have been utterly unaware of the Jimmo Schooling Marketing campaign that CMS was required to offer in 2013.  Additional, even a few of these have been conscious didn’t take part, as over 85% of respondents indicated that they didn’t take part.  CMS supplies proceed to lag as a supply of data as properly, as over 60% of respondents haven’t accessed CMS’ Jimmo webpage.

The Middle for Medicare Advocacy and our allies will proceed our personal efforts to teach suppliers, choice-makers, and beneficiaries about Jimmo, however true systemic change that may guarantee beneficiaries get the protection they’re legally entitled to should contain an actual, ongoing effort by CMS.

For extra info, contact Improvement@MedicareAdvocacy.org

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Well being Care Sabotage: Expanded “Short-Term, Limited-Duration Insurance” is Right here

Beginning this week, shoppers might buy brief-time period, restricted-period insurance coverage insurance policies that may present protection for as much as one yr.  It is very important keep in mind that these skimpy plans have been by no means meant for use as lengthy-time period complete medical insurance. At greatest, they need to be a stopgap for shoppers who expertise a short lived break in protection. Even HHS Secretary Alex Azar stated in a current speech that “these plans aren’t for everyone, and they don’t always offer the same benefits as ACA plans.”

These junk plans “aren’t for everyone” as a result of they don’t seem to be required to abide by Reasonably priced Care Act protection requirements. This so-referred to as “insurance” is just not required to cowl important well being advantages, can deny protection based mostly on pre-present circumstances, gender or age, and may impose annual or lifetime limits on protection. Additional, though these plans supply insufficient protection, they’ve excessive out-of-pocket prices.

As Shopper Studies emphasised within the title of a current report, “Short-Term Health Insurance Isn’t as Cheap as You Think.”

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Research: Three-Day Hospital Requirement for Publish-Hospital Care In a Expert Nursing Facility Increases Medicare Prices

So as to qualify for Medicare Half A protection of a publish-hospital keep in a talented nursing facility, the normal Medicare program requires that the beneficiary first be hospitalized as an inpatient for 3 consecutive days, not counting the day of discharge. This requirement has been in place because the Medicare program was enacted greater than 50 years in the past, when the size of keep in an acute care hospital for individuals age 65 and over was 13 days.[1]  Right now, the typical size of keep for all sufferers is lower than 5 days.[2]

The Enhancing Entry to Medicare Protection Act of 2017 (H.R. 1421, S.568) is federal laws that may rely all time spent in a hospital – whether or not inpatient or outpatient “observation.”[3]  Though there’s robust bipartisan help for this pending laws,[4] the Congressional Finances Workplace (CBO) has not given the payments an official “score” – which means that the CBO has not decided how a lot the laws would value. Congress usually needs laws to be “paid for” and won’t move a invoice until it has been scored by the CBO.

A brand new research of the three-day requirement finds that the three-day inpatient hospital requirement will increase Medicare spending by including prices for each expert nursing amenities and rehospitalizations.[5] The evaluation is predicated on 2.9 million inpatient hospital discharges in 4 states (Arizona, Florida, New York, and Washington) between 2004 and 2013.

The Middle for Medicare Advocacy questions a few of the statements and assumptions made within the analysis – e.g., that sufferers might want to go to a talented nursing facility for pointless care as a result of the care is “free.” However, the evaluation supplies help for the conclusion that the three-day inpatient requirement, by itself, imposes prices on the Medicare program that is probably not needed. 

Definitely medical care in 2018 is totally different from medical care in 1965 and well being care circumstances that required in depth hospitalization 52 years in the past could also be handled fairly in another way right now. Medicare Benefit plans are permitted to waive the three-day hospital requirement and lots of demonstration tasks equally waive the requirement, though the Medicare Cost Advisory Fee is (inexplicably) contemplating a suggestion so as to add an inpatient hospital requirement to all submit-hospital settings.[6]

[1] Middle for Illness Management and Prevention, Sufferers Discharged From Brief-Keep Hospitals by measurement and sort of possession United States-1965, Desk 10 (Dec. 1968),  https://www.cdc.gov/nchs/data/series/sr_13/sr13_004acc.pdf. 
[2] Company for Healthcare Analysis and High quality, “Overview of Hospital Stays in the United States, 2012”  (Oct. 2014),  https://www.hcup-us.ahrq.gov/reports/statbriefs/sb180-Hospitalizations-United-States-2012.pdf. 
[3] Enhancing Entry to Medicare Protection Act of 2017, H.R. 1421, S.568.
[4] As of October 2, 2018, H.R. 1421 is supported by its chief sponsor, Congressman Joe Courtney and 93 co-sponsors and S. 568 is supported by its chief sponsor, Senator Sherrod Brown, and 21 co-sponsors.
[5] Ginger Zhe Jim, “Medicare Payment to Skilled Nursing Facilities: The Consequences of the Three-Day Rule,” Nationwide Bureau of Financial Analysis, Working Paper (Sep. 2018).
[6] “MedPAC Discusses Requiring a Three-Day Hospital Stay for All Post-Acute Care, Threatening Access to Care” (CMA Alert, Sep. 13, 2018), http://www.medicareadvocacy.org/medpac-discusses-requiring-a-three-day-hospital-stay-for-all-post-acute-care-threatening-access-to-care/. 

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Who Owns Nursing Amenities and Why?

In September 2007, The New York Occasions revealed a prolonged investigative article about personal fairness’s buy of nursing amenities – “At Many Nursing Homes, More Profits, Less Nursing.”[1]  The Occasions reported that non-public fairness companies bought amenities and divided possession into a number of corporations, insulating themselves from personal litigation and significant regulatory enforcement. In the meantime, the companies reduce employees and high quality of look after resident declined additional. Deaths and lawsuits have been the end result. The chief instance (and solely firm that may speak to The Occasions) was Formation Capital, which bought Florida nursing amenities. Formation’s CEO Arnold Whitman advised The Occasions, “‘Lawyers were suing nursing homes because they knew the companies were worth billions of dollars, so we made the companies smaller and poorer, and lawsuits have diminished.’” The article ends with the report that, after 4 years, Formation bought the Florida amenities for a revenue estimated to have been greater than $500 million.

Outraged by the investigative report, Congress held hearings and developed laws on accountability and transparency, which have been included into the Reasonably priced Care Act (ACA).[2] The ACA’s transparency provisions haven’t been carried out. The regulation required that the statutory provision turn out to be efficient one yr after publication of ultimate guidelines. CMS issued weak proposed guidelines[3] (primarily copying the language of the statute and asking members of the general public the right way to slender the scope), however it by no means issued ultimate guidelines.[4]

So The place We Are In the present day?

On October 1, 2018, Expert Nursing Information reported that a new three way partnership between Elementary Advisors LP and Senior Care Improvement has “an eventual goal of snapping up $1 billion in skilled nursing assets.”[5]

Senior Care Improvement’s web site features a part referred to as “SNF Investments” that states in full:

There’s a pure development from creating the complete continuum of senior care amenities to buying and investing in them. SCD has accomplished so selectively and efficiently—typically towards prevailing business opinion—whereas sustaining vigilance towards turnaround alternatives. We all know learn how to interpret the underlying points, leap on earlier than the bandwagon rolls, and step off earlier than it pulls up brief.[6]

Such was the case within the following transactions.

One of many 4 transactions was 175 Southeast Nursing Houses, described as follows:

175 Southeast Nursing Houses
Acquired under market, reorganized and restored to profitability, then resold at double the acquisition worth.

An ideal instance of investing “against the grain” occurred when giant numbers of Florida nursing houses, underneath the monetary strain of an overheated insurance coverage legal responsibility setting in 2001 and 2002, turned out there at depressed values. Via its separate affiliated firm, Senior Care Holdings LLC, SCH joined with and invested in Formation Capital LLC-sponsored tasks and, over the subsequent few years, acquired greater than 175 nursing houses with over 21,500 beds in 19 states. Business insiders have been fast to scoff, however not for lengthy. By separating possession of the actual property from the working firm, the funding group was capable of include affected person legal responsibility and restore profitability—creating nothing lower than a paradigm shift within the nursing house business. Subsequently, the revalued portfolio was bought to GE Capital in 2006 for about $1.four billion, greater than twice the unique buy worth.[7]

The New York Occasions underestimated barely how a lot was created from the sale of the Florida nursing amenities after 4 years – it was nearer to $700 million than $500 million.


Clearly, and sadly, nothing has modified since The Occasions’ investigative piece greater than a decade in the past. The accountability and transparency provisions of the ACA haven’t been carried out. However even when that they had been, transparency is just not a adequate response to issues associated to nursing house possession. 

The 1987 Nursing House Reform Regulation describes the broad “duty and responsibility of the Secretary:” 

It’s the obligation and duty of the Secretary to guarantee that necessities which govern the supply of care in expert nursing amenities beneath this subchapter, and the enforcement of such necessities, are enough to guard the well being, security, welfare, and rights of residents and to advertise the efficient and environment friendly use of public moneys.[8]

The federal government has met neither its obligation nor its duty to residents and taxpayers. We name on Congress to behave to make sure that state licensure and federal certification are given solely to house owners and managers that present top quality care to residents.

[1] Charles Duhigg, “At Many Nursing Homes, More Profit, Less Nursing,” The New York Occasions (Sep. 27, 2007), https://www.nytimes.com/2007/09/23/business/23nursing.html. 
[2] Reasonably priced Care Act, §6101, 42 U.S.C. §1320a-three(c)(1)-(5), (b).
[3] CMS, “Medicare Program; Prospective Payment System and Consolidated Billing for Skilled Nursing Facilities; Disclosures of Ownership and Additional Disclosable Parties Information,” CMS-1351-P, 76 Fed. Reg. 36363 (Might 6, 2011), https://www.gpo.gov/fdsys/pkg/FR-2011-05-06/pdf/2011-10555.pdf.
[4] The ultimate guidelines, CMS-1351-F, 76 Fed. Reg. 48455 (Aug. eight, 2011), https://www.gpo.gov/fdsys/pkg/FR-2011-08-08/pdf/2011-19544.pdf, don’t talk about Disclosures of Possession with Further Disclosable Events Info.
[5] Alex Spanko, “Fundamental, Senior Care Development to Form $1 Billion Skilled Nursing Joint Venture,” Expert Nursing Information (Oct. 1, 2018), https://skillednursingnews.com/2018/10/fundamental-senior-care-development-form-1-billion-skilled-nursing-joint-venture/. 
[6] http://seniorcaredevelopment.com/investments.php. 
[7] http://seniorcaredevelopment.com/investments_florida_nursing_homes.php.
[8] 42 U.S.C. §1395i-three(f)(2), 1396r(f)(2), Medicare and Medicaid, respectively.

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