Archive for the ‘Medicare and Medicaid’ Category

CMS to Overhaul Nursing Home Compare

It seems the Centers for Medicare and Medicaid Services (CMS) has been paying attention. While the agency’s five-star rating system for nursing homes has always been the subject of a fair share of criticism, new concerns started gaining speed in the media within the past few months. At the beginning of September, we reported on criticisms surrounding the self-reporting measures and other practices leading some experts to say that they doubt the integrity of the rating system as a true barometer of quality of care.

IMPACT Act aims to improve quality ratings for skilled nursing facilities

On Oct. 6, President Obama signed the Improving Medicare Post-Acute Care Transformation (IMPACT) Act, which aims to improve quality through increased transparency and standardized assessments in several areas surrounding critical care issues across skilled nursing facilities, home health agencies, long-term care hospitals, inpatient rehabilitation facilities, and other post-acute care (PAC) providers. Nursing Home Compare overhauls rating system

IMPACT will allow both payments and patient outcomes to be compared across these providers, fueling the development and public reporting of quality measures and facilitating the provision of new PAC payment models, to be presented to Congress by the Medicare Payment Advisory Commission (MedPAC), according to Long-Term Living Magazine.

New changes directly address recent criticisms

But in direct relation to the current five-star rating system used by CMS to grade skilled nursing facilities, there are some big changes coming, many targeted specifically at areas of concern recently addressed in the media. IMPACT, it’s worth noting, however, was first introduced back on June 26 and enrolled as a bill on Sept. 18.

Long-Term Living Magazine summarizes some of the changes that will occur as a result of the passing of the IMPACT Act of 2014:

  • More quality measures will be added to the rating system, beginning in January 2015, including re-hospitalization rates and anti-psychotic drug use.
  • Staffing data will be gathered directly from payroll records rather than through self-report.
  • Scoring methods will be re-evaluated to ensure they accurately represent the quality of providers earning these ratings.
  • A national auditing system will be rolled out to verify information reported through on-site visits.

New measures taken to verify formerly self-reported data, such as staffing ratios and staff turnover rates, are particularly welcomed by critics. Cheryl Phillips, MD, LeadingAge’s senior vice president of public policy and advocacy, tells Long-Term Living Magazine that staffing is one of the most accurate indicators of quality in long-term care settings.

Self-reported quality measures overshadow accuracy

In fact, it’s the self-reporting measures which the debate has primarily centered on in recent months. The controversy surrounding the hotly debated Medicare star-rating system heated up again after the U.S. Department of Health and Human Services Office of Inspector General released an August 2014 report finding that in a random sampling of 209 nursing homes, only 53 percent of allegations of elderly abuse, neglect, or exploitation are reported to federal agencies.

As self-reporting is currently the relied-upon method the CMS utilizes to gather data which determines a skilled nursing facility’s star rating, this naturally casts a shadow over the perceived accuracy of the ratings.

Sweeping changes to data collection and verification to begin in January 2015

While the improvements are expected to take at least one year to implement, consumers will begin to have access to more legitimate, verified data beginning in January. Nursing homes will begin reporting staffing ratios quarterly, and this information will be verified through payroll documents.

Also beginning in January, nursing homes will be rated on the percentage of residents:

  • Receiving anti-psychotic drugs
  • Re-admitted to a hospital
  • Discharged (released) from nursing home care

Most importantly, the system will eventually provide consumers access to this deeper data, such as staff turnover rates and other quality measures. While the additional measures will begin to be incorporated in 2015, this new data won’t actually be reflected in nursing home ratings until 2016.

These changes represent an increasing demand among today’s savvier consumers for high-quality, independent data that provides a true standard metric for navigating the challenges in decision-making when it comes to placing an aging loved one in senior housing. This is the need aims to address with the Best Senior Living Awards, an independent rating system for assisted living, independent living, and other senior housing options to provide families with a standard metric and valid, third-party ratings from experts to aid the decision-making process.

Medicare’s 5-Star Rating System Under Fire

Medicare’s star-rating system for nursing homes, dubbed Nursing Home Compare, is no stranger to controversy. On its launch in 2008, the long-term care community was up in arms, criticizing the system’s lack of quality metrics that play a key role in resident satisfaction. And a new report by a major newspaper has brought critiques of the system back into the forefront.

New criticisms emerge pointing to flawed ratings

According to a recent article in The New York Times, “The Medicare ratings, which have become the gold standard across the industry, are based in large part on self-reported data by the nursing homes that the government does not verify.”

The article points out that only one of the metrics used to determine a nursing home’s star rating comes from independent reviewers: state inspection data. Staffing ratios and quality measures are self-reported by skilled nursing facilities (SNFs), opening the door for potential abuse of the system.

Criticisms of Nursing Home Compare are nothing new; the program has faced them since its inception. But the content of the complaints has changed course over the years.

Early criticisms of Nursing Home Compare

The American Health Care Association (AHCA) denounced Nursing Home Compare in a public statement, voicing the view that the program “is premised upon a flawed survey system that does not measure quality, lacks the inclusion of other important quality elements that help consumers make informed decisions, and includes inaccurate data.”

The general consensus was that nursing homes could be unfairly portrayed or perceived as providing a lower quality of care, based on technicalities that resulted in deficiencies on state inspections. In other words, a lower five-star rating could be assigned to a skilled nursing community that provides exceptional care, and providers were concerned that they’d lose potential residents as a result of such inaccurate ratings.

Nursing Home Compare


Ratings lack critical state complaint data

What’s more, Nursing Home Compare does not take into account complaints filed by consumers with state agencies or fines and other enforcement actions by individual states, only federal actions. The Times points to one community, Rosewood Post-Acute Rehab, a nursing home in a Sacramento suburb, which has maintained a perfect five-star rating for five years, a distinction held by just one-fifth of all nursing homes in the U.S.

But what this rating doesn’t disclose to consumers is the fact that Rosewood was fined $100,000 in 2013, the highest penalty possible, for an accidental, and unfortunately fatal, overdose in 2006. It also doesn’t tell consumers that there have been more than 100 complaints filed in California against this particular nursing home between 2009 and 2013.

California Advocates for Nursing Home Reform, an organization which also tracks complaints, has documented 164 complaints for the same time frame against Rosewood. Officials from Rosewood point out that only a small portion of those complaints have ever been validated, but according to The New York Times, experts say that merely being the subject of that number of complaints is a sign of potential trouble.

But consumers need a clear metric for comparison

While there are some changes coming that will hopefully improve the validity of the Nursing Home Compare rating, such as the requirement that Medicare use payroll data to verify reported staffing levels (required under the Affordable Care Act), a process and system for doing so hasn’t yet been finalized. Best Senior Living Awards Winner Badge

Perhaps of major concern is the idea that a standard, industry-wide rating system is such a valuable metric for consumers. It provides a single point of comparison to help families wade through what can otherwise be a confusing and overwhelming decision-making process. That’s why has created the Best Senior Living Awards, an independent, third-party rating system for assisted living, independent living, and retirement communities.

The Best Senior Living Awards rating system utilizes the opinions of independent senior living experts, along with reviews from residents, staff, and family members, and other quantifiable metrics like state inspection data, to calculate a standard score that consumers can use to easily compare their top communities. Additionally, written reviews are publicly available on, providing consumers with in-depth opinions from others with real-world experience with these communities. Visit any community’s profile on, such as Dunwoody Pines in the Greater Atlanta, Georgia metro area, and access reviews submitted by residents, family members, and staff. And, if you have experience with a senior living community and would like to share your opinion with seniors and their families searching for senior housing options, visit our Post a Senior Living Review page to search for the community and submit your review.

There’s so much information out there about senior living options, yet the choice isn’t an easy one for seniors or their families. There’s a clear need for an independent, third-party rating system that provides a clear, straightforward rating taking into account both quality and compliance, quantitative and qualitative data. And that’s precisely what aims to achieve.

Nursing Home Compare screenshot via

What the Obama Administration is Doing to Help America’s Caregivers

The Affordable Care Act, initiated by the Obama Administration in 2009, will have certain effects on in-home caregiving. Those that are interested in finding out more may want to discuss the changes with their local health care exchange or expert, as they are quite extensive.

The White House

Photo courtesy of U.S. Embassy Jakarta, Indonesia

But in general, the Affordable Care Act makes it easier to get quality health care at a lower cost, and this includes in-home caregiving and care transitions.

Less Expensive, More Benefits

Patients will no longer be able to be denied by their insurance regarding pre-existing health conditions, there will be no coverage caps and prescription costs will be far lower. This is good news for those with in-home caregivers, as many of them were previously affected by these issues.

On the health care side, more funding will be going to direct care workers and family caregivers for elderly patients. The changes made by the Affordable Care Act make it less expensive for most people, especially older adults aged 55-65, to get health care and make preventative health care largely free.

Improve Training for Care Workers

Apart from the benefits for individuals, the Affordable Care Act is projected to bolster the long-term care workforce overall, with training programs that will support these valued workers. Not only do these workers contribute to long-term care in general, but they are also invaluable resources for caregivers that need additional help. States are also encouraged by the Affordable Care Act to expand their current resource offerings under Medicaid.

Resources are being offered to help caregivers make better choices regarding the care of their patients, such as the development of aging and disability centers that will help individuals make difficult decisions regarding care.

Protecting Residents of Long-Term Care Facilities

Finally, the Affordable Care Act includes some provisions for protecting those that are currently residing in long-term care facilities. These long-term care changes include increases in reporting and compliance necessary for nursing homes, requiring abuse prevention training and changes in the way nursing home closures and transfers are currently handled. These changes meant to address issues in long-term care elder abuse that have arisen in recent years. Quality of care issues are being regulated more under the Affordable Care Act for the safety of patients.

The Affordable Care Act is undoubtedly a positive thing for many caregivers and their loved ones as it gives them a larger pool of wealth and knowledge from which to draw. Seniors will find that they have significantly more coverage and family caregivers will have a larger set of resources regarding their needs as a caregiver. Caregivers will be able to reach out to a variety of communities and departments for information and help regarding a large volume of caregiving topics.

The Fiscal Cliff Deal: Medicare Cuts for Physicians Averted

Almost 24 hours past the midnight, December 31, 2012 deadline, Congress cut a last-minute deal to avoid the impending “fiscal cliff” and the potentially devastating economic circumstances which would result from planned tax increases and spending cuts scheduled to take effect. The deal isn’t a fix-all, but more a band-aid to buy leaders more time to negotiate longer-term solutions to some of the nation’s most worrisome problems.

Physicians temporarily saved from massive cuts

The deal will have major ramifications on the healthcare system, affecting many seniors in a number of ways. One of the biggest potential crises, a Medicare pay cut to physicians, has been avoided but at the cost of cutting payments to other providers — including hospitals. The scheduled cuts would have cut physician payments by 27 percent, causing many doctors to say they’d have to stop seeing Medicare recipients.

Image by Yuya Tamai on Flickr

A major change to the way Social Security cost-of-living increases has also been avoided, at least for now. Some leaders were pushing to adjust the calculation to a chained-CPI model, which would have reduced Social Security payments to seniors over the long term.

Medicare payment cuts hit hospitals

Of course, the major victory for physicians doesn’t come without a cost: Those $30 billion in funds will be covered by cuts to hospitals, a move providers aren’t thrilled about. Over 10 years, $10.5 billion will be saved by reducing Medicare base payment increases for inpatient care. An additional $4.2 billion over the same time period will be saved by reducing the Medicaid Disproportionate Share Hospital payments, according to Healthcare Finance News. Finally, payments for end-stage renal disease treatments will be re-priced for a potential savings of $4.9 billion over the next decade.

Rich Umbdenstock, president and CEO American Hospital Association, says these cuts will impact hospitals’ ability to provide care for senior citizens. Jeremy Lazarus, MD, president of the American Medical Association, points out that the Medicare program is unreliable due to the current practice of enacting temporary fixes each time current legislature is set to expire, and says the cuts will hinder Medicare’s progress in developing more effective delivery models for the benefit of seniors.

What’s to come?

Many Republican leaders are left frustrated after this final-hour agreement, regretful that the bill does not include any spending cuts. Republican leaders initially pushed hard for major spending cuts which would help control the federal deficit. In the end, they chose to vote on the bill as-is to avoid setting negotiations in motion again which could have significantly stalled progress and sent the nation into a severe financial crisis if middle-class tax cuts were allowed to expire, unemployment benefits halted for millions of Americans and physician payment cuts went into effect.

By March, Congress will be faced with making the decision to raise the debt ceiling to cover additional costs the current deal will add which aren’t offset by savings elsewhere, such as the $30 billion unemployment extension. It’s likely that a push for cost-cutting measures to Medicare, Medicaid and Social Security will be revisited at that time.


The Changing Landscape of Medicare for 2013 and Beyond

This is a guest post contributed by Shannon Martin, M.S.W., CMC is Director of Communications for Aging Wisely, LLC and EasyLiving, Inc

Medicare recipients will experience a variety of changes in 2013, as a result of healthcare reform measures, annual changes and various occurrences within the healthcare system.

The Affordable Care Act included a number of changes to the Medicare program.  Preventative care coverage has been expanded to cover many screenings.  Participants can take advantage of an annual wellness exam to plan which screenings are appropriate for them each year.  Healthcare reform included changing the “donut hole” provision to Medicare’s drug coverage (part D) and the donut hole will be phased out by 2020 (the donut hole is a period in which recipients pay all drug costs when they reach a certain cost level, up until reaching catastrophic coverage).  In 2013, people who hit the donut hole will have additional help/discounts during that period.

Medicare 2013

Image by Images_of_Money via Flickr

Some of the changes that the Affordable Care Act implemented are more provider-oriented, such as quality care incentives and penalties for things such as “avoidable” hospital readmissions.  A number of cost savings measures were implemented in order to pay for new additions, but additional cuts may be necessary if the measures do not work as predicted.  Many experts predict there will be a lot of changes in the Medicare Advantage market, as significant changes to that payment system roll out.

Medicare recently published the 2013 copays, deductibles and other Medicare costs and most are increasing slightly.  Here are some of the primary

2013 Medicare cost updates:

The standard Medicare B monthly premium will increase from $99.90 to $104.90 (higher income individuals will pay more).

The Medicare B (yearly) deductible will increase to $147.

The Medicare A hospital deductible (for stays up to 60 days) will be $1184 and the skilled nursing facility co-pay will be $148 per day (for days 21-100, the first 20 days are covered at 100%).

You can visit for more details or download Aging Wisely’s 2013 Medicare Fact Sheet.

Skilled Nursing and Rehabilitation Requirements: Lawsuit Settlement

The U.S. Department of Health and Human Services recently settled a class action lawsuit (Jimmo v. Sebelius) regarding Medicare’s coverage requirements for skilled nursing and rehab. services.  Medicare typically denies coverage for skilled nursing and rehabilitation (under Part A) if a patient does not demonstrate an ability to improve.  This class action lawsuit addressed patients who need skilled nursing and rehabilitation services to manage a condition (which may not be expected to improve) or maintain their current health.

Patients must still demonstrate a need for skilled care and meet all of the other criteria (visit or grab a summary at Paying for Home Care Tips).  Many patients rely on “custodial care” (help with activities of daily living, household assistance), which will remain outside the scope of Medicare coverage.  However, this change could have significant impacts on patients who have chronic conditions and rely on occasional skilled care and therapy to maintain functioning and health.

These changes will be rolling out over the next several months to providers and consumers.  In the meantime, a number of Medicare beneficiaries who were denied benefits for skilled services (before January 18, 2011 when the lawsuit was filed) will have their claims re-examined.  It is an important issue to be aware of and seek help if you (or a loved one) feel you are being denied services under these new standards.  You can file an appeal through Medicare’s appeals process or seek help from a patient advocate to understand requirements, care options and ways to appeal or find alternatives.

Medicare Expansion Ignores Long-Term Care Needs

Last week, Medicare entered into an agreement to settle a lawsuit brought by a Vermont-based woman named Glenda Jimmo in conjunction with the Center for Medicare Advocacy and other plaintiffs, according to As part of the settlement, Medicare has agreed to expand skilled nursing cares and rehabilitation benefits for some individuals with chronic disease. But what this settlement does not include is an expansion of long-term care benefits.

No long-term care benefits

Medicare has never provided coverage for long-term care, which can be a common misconception. Medicare covers only skilled nursing care, which includes physical and occupational therapy as well as complex nursing care, such as IV therapies or wound care. And Medicare only provides coverage for skilled care for a short duration, after which it becomes the patient’s responsibility to continue paying for care out-of-pocket. Only if another qualifying hospital stay occurs can an extension of skilled nursing benefits occur.

Medicare settlement won't expand long-term care benefits

Image by juliaf on Stock.xchng

Long-term care, on the other hand, is also known as custodial care. Medicaid will cover long-term care in some cases, but not all.

Clarifying vague language on maintenance therapy

This settlement won’t change the duration of coverage for skilled nursing care, which has a maximum of 100 days. It will, however, clarify vague language. Providers have been reluctant to continue providing skilled care to patients who were not continuously improving as a result of that care, fearing that payment would be denied. But now, patients are eligible to receive skilled care even if that care doesn’t cause improvement but allows the patient to maintain her current health status.

Skilled nursing care must be deemed necessary by a medical professional or based on an individual assessment, but doctors will no longer have to certify that patients will improve as a result. points out that these changes could actually end up saving the Medicare program money in the long run. Ongoing therapies can help patients maintain their current health status, preventing more frequent hospitalizations.

While a judge must enter the ruling for it to become official, Medicare will already begin to implement these changes. Still, it could take months for the changes to be in full effect.