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HHS Inspector General Finds Millions in Erroneous Part D Payments for Skilled Nursing Patients

Of the $75 million spent by Medicare Part D to cover 1.2 million prescription drugs for patients in skilled nursing facilities in 2006, the “majority of these payments were most likely inappropriate,” the Department of Health and Human Services’ Office of Inspector General (OIG) has concluded.

The OIG urged CMS to ensure that Part D payments for drugs for beneficiaries in Part A SNF stays are appropriate. More specifically, CMS should provide additional guidance about when Parts A and D can pay for drugs for beneficiaries preparing for discharge; educate SNFs, pharmacies, and Part D sponsors that drugs covered under Parts A or B for beneficiaries in SNF stays are not eligible for coverage under Part D; implement retrospective reviews to prevent inappropriate Part D payments for drugs for this population; and follow up with the SNFs and pharmacies that were responsible for a large percentage of Part D payments for beneficiaries in Part A SNF stays.

Medicare Part D covers most prescription drugs; however, it excludes drugs that are covered under Medicare Parts A or B. Specifically, Part D excludes drugs for beneficiaries in Part A SNF stays if the drugs were for use in the facility or to facilitate the beneficiaries' discharge. These drugs are covered under Part A, except for a few drugs that are covered under Part B. CMS has identified duplicate payments by Medicare Parts A and D as a potential vulnerability.

Sixty percent of the drugs Part D paid for while beneficiaries were in Part A SNF stays in 2006 were dispensed by long-term care pharmacies. These pharmacies dispense drugs for use in long-term care settings, including SNFs. Because these drugs were most likely dispensed for use in the facility during a Part A SNF stay, Part D payments for them, which amounted to $41.3 million, were most likely inappropriate, OIG concluded.

The remaining 40 percent of drugs paid for by Part D for beneficiaries in Part A SNF stays were dispensed by retail and other types of pharmacies. If these drugs were for use in the facility or were to facilitate the beneficiaries' discharge, then Part D payments were also inappropriate.

Nearly every SNF and half of all pharmacies had beneficiaries who had a drug paid for by Part D during their Part A SNF stay. At the same time, a small number of SNFs and pharmacies were responsible for a large percentage of these Part D payments.

To view the OIG report, go to: http://www.oig.hhs.gov/oei/reports/oei-02-07-00230.pdf

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Special Committee on Aging Looks at Long-Term Care Insurance Industry
June 3, 2009

Senators Herb Kohl (D-WI) and Mel Martinez (R-FL) of the Special Committee on Aging examined the long-term care insurance (LTCI) industry at a hearing held this week. The high cost of long-term care and the current economic instability are creating significant financial planning challenges for baby-boomers, seniors, and individual states. The committee discussed the industry's current limitations and how to prepare for the growing number of seniors who will be in need of long-term care.
Click here to view rest of story

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AoA Announces HHS-VA National Partnership to Support Older Americans and Veterans
June 4, 2009

Acting Assistant Secretary for Aging Edwin L. Walker, speaking June 4 before the House Committee on Veterans Affairs Subcommittee on Health, announced the availability of $10 million in funding for collaboration between the Department of Health and Human Services and the Department of Veterans Affairs to develop a nationwide community-based long-term support program to help older Americans and Veterans of all ages with Disabilities remain in the community.

This partnership builds on the similar missions of HHS and the VA with regard to caring for the populations they serve.

Go to: http://www.hhs.gov/news/press/2009pres/06/20090604a.html
 
Walker also announced the availability of $2.5 million in funding for the new Lifespan Respite Care Program Grants to provide family caregivers with more opportunities to receive much-needed short-term, temporary relief from providing care for their loved ones. These projects will enable states to establish, enhance or expand Lifespan Respite Care systems, including new and planned emergency respite services, training and recruitment of respite workers and volunteers and assist caregivers with gaining access to needed services in their communities. 
Go to: http://www.aoa.gov/AoARoot/Press_Room/for_the_press/pr/archive/2009/June/06_04_09.doc

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Medicare/Medicaid Fall-Prevention Changes May Lead to Increased Use of Physical Restraints
June 4, 2009

A Congressional mandate to protect hospital patients from falls, put in effect by the U.S. Centers for Medicare and Medicaid Services (CMS), could inadvertently have adverse consequences, according to Beth Israel Deaconess Medical Center gerontologist Sharon Inouye, MD, MPH. Inouye is a Professor of Medicine at Harvard Medical School and Director of the Aging Brain Center at Hebrew Senior Life.

"In 2005, in response to disturbing and widely cited findings by the Institute of Medicine about the prevalence of life-threatening conditions acquired by patients in U.S. hospitals, Congress authorized the CMS to implement payment changes designed to encourage the prevention of such conditions," Inouye and coauthors wrote. “As such, Medicare will reduce reimbursement rates to hospitals if one of eight hospital-acquired conditions develops during the patient's stay; hospital falls and trauma were included as one of these eight.

"Our greatest concern is that the heightened focus on fall prevention will have unintended consequences," notes Inouye. These are likely to include a decrease in mobility and a resurgence in the use of physical restraints and other restraining devices, such as bed alarms, in what Inouye calls "a misguided effort to prevent fall-related injuries.

"While hospitals are understandably concerned about reductions in reimbursement as well as the public reporting of fall rates that could emanate from this mandate, the use of physical restraints can create other problems," she adds.

Physical restraints have long been used because they are believed to prevent falls. But studies have consistently shown that not only are restraints ineffective in reducing the risk of falls and related injuries, they are actually associated with increased rates of medical complications, including immobility, functional loss, delirium, agitation, pressure sores (which are themselves one of the non-reimburseable hospital-acquired conditions), asphyxiation, and death. Moreover, accumulating evidence suggests that restraints may actually increase the risk of falling or sustaining an injury from a fall.

"At present, there are no proven strategies that are documented to be effective in preventing falls in the hospital setting," explains Inouye. However, she adds, because previous studies have indicated that a change in mental status is the leading risk factor for falls in the hospital, strategies that incorporate multiple components may prove beneficial.

The authors emphasizes that there are alternatives to physical restraints that can help keep patients safe. They cited the Hospital Elder Life Program (HELP), which prevents the onset of delirium through a number of interventions targeted at maintaining mobility, orientation, hydration and sleep. Early evidence lends strong support that this program is also effective in preventing falls.

See the June 4 The New England Journal of Medicine, http://content.nejm.org/cgi/content/short/360/23/2390.

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Medicare Part D Too Complicated for Seniors to Identify Lowest-Cost Plan
June 3, 2009

Older adults are not doing a good job at figuring out their lowest-cost option for their Medicare Part D prescription plans. A new study found they were less likely to identify the plan that minimized their total annual cost and were likely to mistakenly think they had chosen the lowest-cost plan. The study, funded by the Robert Wood Johnson Foundation Investigator Awards in Health Policy Research.

"Many seniors are unaware that they can be saving hundreds of dollars every year by choosing a different drug plan, because there are entirely too many choices for them to navigate," said Yaniv Hanoch, Ph.D., lead author and lecturer at the University of Plymouth, School of Psychology, Plymouth, U.K. "The system should limit choice and empower its beneficiaries to make informed and cost-effective decisions about their prescription drug plan."

Hanoch and colleagues looked at consumer behavior patterns of nearly 200 mentally and physically healthy individuals age 18 and older. Half were age 65 or older. The researchers found that—regardless of age—an increase in the number of insurance plans available reduced the likelihood of picking the plan with the lowest annual costs.

Other factual questions about the plans were also more likely to be answered incorrectly when participants had more plans to choose from. While older adults were less able than younger ones to choose the plan that offered the lowest annual costs, they were also more confident that their decisions were correct.

The authors recommend a few options for improving the system: offering one choice that seniors can opt in or out of (like Medicare Parts A and B); standardizing the benefit; or reducing the number of plans to 10 or less.

The study will be published in the August 2009 issue of Health Services Research. Go to: http://www3.interscience.wiley.com/journal/122407933/abstract.

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Improper Medicare and Medicaid Payments Comprise 50% of Government Mis-spending, GAO Tells Congress
May 1, 2009

Improper payments by Medicare and Medicaid represent 50% of government-wide improper payments reported in fiscal year 2008, according to the General Accountability Office (GAO). The Department of Health and Human Services (HHS) reported improper payment estimates for Medicare and Medicaid totaling about $36 billion for fiscal year 2008. [Government-wide, federal agencies reported improper payment estimates of $72 billion for fiscal year 2008, which represented about 4% of the $1.8 trillion in outlays for those programs.]

In 2008, HHS reported improper payment amounts of $10.4 billion in Medicare Fee-for-Service and $6.8 billion in Medicare Advantage, Kay L. Daly, GAO’s Director for Financial Management and Assurance told the Senate Committee on Homeland Security and Governmental Affairs on April 22. The FY 2008 data represents the first year that CMS reported estimated improper payments for Medicare Advantage, with an error rate of 10.6% or $6.8 billion in estimated improper payments. While HHS performed medical record reviews, they did not specifically identify the types of attributes tested to identify the improper payments.

HHS also estimated a Medicaid improper payments rate of 10.5%, or $18.6 billion for the federal share of expenditures for fiscal year 2008. This Medicaid improper payment estimate represents the largest amount that any federal agency reported for a program in fiscal year 2008.

While CMS has taken steps to enhance its program integrity efforts, further work remains to put in place the internal controls necessary to effectively identify and detect improper payments, Daly said. GAO’s recent work in Medicare continues to identify fraudulent and abusive practices within the program.

For example, GAO’s work on Medicare's home health care administration and enrollment of durable medical equipment suppliers found weaknesses that exposed the program to significant improper payments. The magnitude of Medicaid improper payments indicates that CMS and the states face significant challenges in addressing the program's vulnerabilities in estimating national improper payment rates for diverse state-administered programs.

GAO’s review of Medicare’s spending on home health care found that home health agencies’ practice of upcoding (overstating the severity of a beneficiary’s condition), providing kickbacks, and billing for services not rendered contributed to Medicare’s home health spending and utilization. We reported that inadequate administration of the Medicare home health benefit left the program vulnerable to improper payments.

GAO’s review of enrollment of Medicare’s durable medical equipment suppliers found weaknesses in Medicare’s screening process that exposed the program to potentially paying millions of dollars for medical equipment and supplies that were not necessary or were not provided to beneficiaries.

Similarly, challenges exist for the Medicaid program. The HHS Office of Inspector General has reported that CMS’s efforts to identify payment errors, their causes, and vulnerabilities in Medicaid is particularly challenging because of the diversity of state programs and the variation in their administrative and control systems.

Given the staggering size of these programs’ expenditures, even small amounts of payment error can have a significant impact on both federal and state treasuries and taxpayers, Deb Taylor, Acting Director of the CMS Office of Financial Management told the committee.

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Social Security COLA Freeze and Medicare Part B Premium Hike Reduces Income for Some
May 28, 2009

Social Security recipients are not expected to receive a cost-of-living adjustment (COLA) for the first time in 2010, with no or low COLAs projected through 2012. The absence of a COLA will result in higher Medicare Part B premiums for roughly a quarter of all Medicare beneficiaries, with a particularly steep increase in premiums expected between 2010 and 2011, according to an analysis by the Kaiser Family Foundation.

With Medicare Part B spending expected to continue to increase in the coming years, beneficiary premium contributions are also expected to rise to cover 25 percent of total Part B spending as required by law.

Not all Medicare beneficiaries will be affected. About three in four Medicare beneficiaries are protected by a “hold-harmless” provision in the law that ensures that their Medicare premiums do not increase more than any increase in Social Security premiums. Thus, the higher premiums would fall on the remaining one quarter of beneficiaries?- -  those with monthly premiums expected to rise from $96.40 this year to $104.20 in 2010 and $120.20 in 2011.

Because most in this group are low-income beneficiaries eligible for both Medicare and Medicaid benefits, Medicaid would pay the cost of the monthly Part B premium, increasing Medicaid costs for states. Higher-income beneficiaries who are required to pay an income-related surcharge in addition to the monthly Part B premium would also pay the higher rate, as would any new enrollees who did not receive Social Security payments in the previous year and/or were not covered under Part B.

See Kaiser Family Foundation Issue Brief, “The Social Security COLA and Medicare Part B Premium: Questions, Answers, and Issues.”

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Stanford Study Expands Window for Effective Stroke Treatment
May 28, 2009

Research from the Stanford University School of Medicine indicates that the window for stroke treatment might be a bit wider than thought before. If a patient arrives at the emergency room within three hours of experiencing stroke symptoms, doctors can administer a potent clot-busting medication and often save critical brain tissue. But if more than three hours have passed, current clinical guidelines say the medication should not be used.

But the new study suggests that the traditional three-hour time window is too short. By combining data from multiple clinical trials, Maarten Lansberg, MD, PhD, assistant professor of neurology and neurological sciences at Stanford, and colleagues from Belgium and Germany showed that treatment can benefit patients up to 4.5 hours after they experience their first symptom. Their findings were published online May 28 in the journal Stroke.

Every year, more than 750,000 Americans experience a stroke, or brain attack, due to a sudden drop in blood flow to the brain. Most strokes are ischemic, meaning they're caused by a blocked artery. For these strokes, a medication called tissue plasminogen activator, or tPA, can open blocked blood vessels and help restore blood flow to the brain.

"We've known that this treatment works for ischemic stroke since 1995," said Lansberg, the lead author of the study. "But in the United States, only about 3 percent of stroke patients end up getting treated. Most of them are ineligible because they come to the hospital after the three-hour time window."

The timing of treatment is important, because giving a strong blood thinner like tPA during a stroke can cause bleeding inside the brain. The longer a patient waits to get treatment, the more likely it is that the risks of treatment will outweigh the benefits.

Among a total of 1,622 patients who arrived at the hospital between three and 4.5 hours after their symptoms started, treatment with tPA improved the odds of a favorable outcome by 31 percent.

"A favorable outcome means that patients are either completely back to normal or they have minimal symptoms, like some numbness or a slight facial droop," Lansberg said. "But they can do everything in their normal life that they were able to do before the stroke happened."

The study, funded by grants from the National Institutes of Health, found no change in the death rate among patients treated with tPA during the three- to 4.5-hour window. In other words, treatment improved outcomes without negatively affecting mortality.

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AARP Public Policy Institute Releases Plan for Better Cities
May 29,2009

A new report from the Public Policy Institute at AARP examines the need to create “Complete Streets” that are safe and convenient for travel by automobile, foot, bicycle and transit regardless of age or ability. The study encourages roadway planners and engineers to approach road design through the lens of Complete Streets and employ design strategies that support older drivers and pedestrians. Findings from original research conducted for this study show that:
 
Two-thirds of planners and engineers report that they have not yet begun considering the needs of older road users in their multi-modal planning.
 
More than 80 states and localities have adopted Complete Streets policies, but less than one-third of these explicitly address the needs of older road users.
 
Forty percent of adults age 50 and older report inadequate sidewalks in their neighborhoods. More sobering, nearly 50 percent report they cannot cross main roads close to their home safely.

The report suggests revisions to five intersection treatments in the Federal Highway Design Handbook for Older Drivers and Pedestrians to better balance the needs of both older drivers and pedestrians. 

See “Planning Complete Streets for an Aging America”

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2009 Community College Caregiver Training Initiative: Request for Proposals
May 26, 2009

ILC-USA and the Schmieding Center for Senior Health and Education, with support from MetLife Foundation, are seeking applications from community colleges and other two-year institutions for the Caregiving Project for Older Americans.

The purpose of the initiative is to encourage the development of new and novel programs to train both family caregivers and in-home care workers, promote skill development, advance the quality of care, and provide opportunities for career development. In addition, the Initiative will raise national awareness both of the critical need for caregiver training and of the central role that community colleges can play in providing this training.

Up to 15 grants of up to $20,000 will be awarded as part of the 2009 Community College Training Initiative grants. These grants encourage community colleges to develop training programs that are both accessible and effective for caregivers of older adults.

The deadline for submissions is June 8.

Go to: http://www.ilcusa.org/pages/media_items/2008-community-college-caregiver-training-initiative-request-for-proposals185.php

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Heinz Family Philanthropies Release New Fact Sheets On Questions Families Should Ask About Long-Term Care
May 18, 2009

Figuring out long-term care is complicated and very often families do not even know which questions to begin asking when they start -- or when they are suddenly forced--- to consider it.

The Heinz Family Philanthropies has added a new series to its Facts About project entitled “10 QUESTIONS TO ANSWER… About Long-term Care.”  The 10 Answers provide unbiased information related to important issues about long-term care. 

10 QUESTIONS TO ANSWER… poses a series of questions for older adults and their families to consider when deciding about long-term care. They provide brief answers, ideas for further consideration, and links to resources that can help families dealing with these difficult issues.


The 10 QUESTIONS TO ANSWER …  series will be first available as online fact sheets and within the next 30 days as 3”x5” laminated index cards.

Previous editions have covered such issues as Prescription Drugs and Seniors, Health Care Cost and Coverage, Women’s Pensions and Retirement Benefits, and Health of College Students.
 
The five new fact sheets in the “10 Questions” series are:

10 Questions to Answer Before You or a Your Loved One Needs Long-Term Care…
These questions examine long-term care options beyond nursing home care.

10 Questions to Answer Before You or a Your Loved One Purchase Long-Term Care…
These questions look at the financial aspects of long-term care.

10 Questions to Answer Before Choosing a Nursing Home or Assisted Living…
These questions will provide you with a logical process for selecting a new home that best matches your needs and lifestyle, or those of a loved one. 

10 Questions to Answer Before Managing Your Long-Term Care Services…
These questions examine how you define what is important and preferred by you or your loved one when living into great old age or with a disability.

10 Questions to Answer When You Are Not Happy with Your Long-Term Care…
These questions address options on how to handle situations when you think the care you are getting is not what or how you really want it. 

Go to: www.tenquestionstoanswer.org.

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Medicare Trustees Foresee Trouble by 2017
May 12, 2009

The Medicare Hospital Insurance Trust Fund will be out of money to meet its expenditures in 2017, two years earlier than last year’s prediction, according to the 2009 Medicare Trustees Report released May 12. Medicare expenditures totaled $468 billion in 2008, the report said.

In 2008, 45.2 million people were covered by Medicare: 37.8 million aged 65 and older, and 7.4 million disabled. About 22% of beneficiaries have chosen to enroll in private health plans that contract with Medicare to provide health services. Total benefits paid in 2008 were $462 billion. Income was $481 billion, expenditures were $468 billion, and assets held in special issue U.S. Treasury securities grew to $381 billion.

“The financial outlook for the Medicare program continues to raise serious concerns,” the report states. “Total Medicare expenditures were $468 billion in 2008 and are expected to increase in future years at a faster pace than either workers’ earnings or the economy overall. As a percentage of GDP, expenditures are projected to increase from 3.2% in 2008 to 11.4% by 2083 (based on our intermediate set of assumptions). Growth of this magnitude, if realized, would substantially increase the strain on the nation’s workers, Medicare beneficiaries, and the federal budget.”

Health and Human Services Secretary Kathleen Sebelius said, “Today's report should trouble anyone who is concerned about the future of Medicare and health care in America. … This isn't just another government report. It's a wake up call for everyone who is concerned about Medicare and the health of our economy. And it's yet another sign that we can't wait for real, comprehensive health reform.” She said HHS would use its administrative authorities to help keep Medicare costs in check and fight Medicare fraud.

Robert Greenstein, executive director of the Center on Budget and Policy Priorities (CBPP) told reporters that it was a “disturbing report.” He called for Congress to adopt the president’s Medicare reform plan, saving $266 billion over 10 years.

Greenstein also said Congress should adopt MedPAC’s recommendation to stop sending billions in overpayments each year to private insurance companies participating in Medicare. “MedPAC has reported that Medicare now pays the private insurers, who provide Medicare coverage to about a fifth of Medicare beneficiaries, 14% more on average — about an estimated $1,000 more per beneficiary each year — than it would cost to cover the same beneficiaries under regular Medicare,” according to CPBB. The House in 2007 adopted MedPAC’s recommendation to pay the private insurance companies what it would cost to treat these patients under regular Medicare, but the Senate failed to act on it.

The Part B (physician and outpatient services) and Part D (prescription drug) accounts in the SMI trust fund are adequately financed under current law, since premium and general revenue income are reset each year to match expected costs. Such financing, however, would have to increase rapidly to match expected expenditure growth under current law, the Trustees said.

To view the report, go to http://www.cms.hhs.gov/ReportsTrustFunds/downloads/tr2009.pdf .

Meanwhile, the Social Security Trust Fund will be able to continue to pay full benefits until 2037, according to the new report from the Social Security Trustees released May 12. At that point, the fund will not be totally exhausted, but will be able to pay 75% of scheduled benefits. To View the Social Security Trustees report, go to: http://www.ssa.gov/OACT/TR/2009/trTOC.html.

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Administration Seeks $11 Million Hike for Geriatric Education; Level-Funds Most AoA Programs; Phases Out Real Choice
May 7, 2009

The Obama administration’s FY 2010 budget request seeks a $11 million increase for geriatric education programs at the Health Resources and Services Administration. The funds support health care workforce programs that target geriatrics and better prepare for the aging population. This increase will support an additional 6 Geriatric Education Centers, 3 Geriatric Training for Physicians, Dentists, and Behavioral and Mental Health Programs, and 12 Geriatric Academic Career Awards, according to the Department of Health and Human Services budget justification documents.

The FY 2010 budget in its entirely was released May 7. A preliminary budget released in February contained only a few line-item funding details.

Click here to see a table of key funding levels.

ADMINISTRATION ON AGING
For the Administration on Aging, the budget request would fund most programs at the levels contained in the FY 2009 omnibus appropriations bill. The two exceptions are:

     Choices for Independence. There would be a $3 million hike for Health and Long-Term Care Programs, previously known as Choices for Independence programs. These include Aging and Disability Resource Centers, Evidence-Based Disease and Disability Prevention Programs and Nursing Home Diversion.

     Program innovations would be cut by $5 million. That is because the request does not include funding for one-time, one-year congressional earmark projects whose selection was incorporated into law by reference in the FY 2009 Omnibus. Click here to view a detailed list of expenditures. AoA Program Innovations.pdf

     The links below show state funding levels for
Home and Community-Based Supportive Services.pdf
Home-Delivered Nutrition Services.pdf
Congregate Nutrition Services.pdf
Nutrition Services Incentive Program.pdf
Prevention of Elder Abuse, Neglect, and Exploitation.pdf
Long-Term Care Ombudsman Program.pdf
Family Caregiver Support Services.pdf
Preventive Health Services.pdf

Click here to view funding levels for Aging Network Support Activities.


CENTERS FOR MEDICARE & MEDICAID SERVICES.

     Health care fraud and abuse programs would increase from $198 million to $311 million, as part of the administration plan to crack down on Medicare and other fraud.

     Real Choice. CMS proposes to reduce funding for the Real Choice Systems Change grants that help states develop improvements in community-based supports for individuals with disabilities. The budget request noted that these grants are being reduced since there is larger mandatory funding (such as Money Follows the Person) available for this type of activity. The budget request includes $2.5 million to fund Real Choice Systems Change grant, a decrease of $2.5 million below the FY 2009 enacted level. Funding will eventually be phased-out.

     SHIPs. CMS funding for the State Health Insurance and Assistance Program (SHIP) would drop from $54.9 million in FY 2009 to $43.3 million in the FY 2010 budget request. However, the budget documents point out that SHIPs received an additional $15 million in state grants via the Medicare, Medicaid, and SCHIP Extension Act. In FY 2009, the SHIPs received $7.5 million from the Medicare Improvements for Patients and Providers Act of 2007 for targeted beneficiaries for Medicare enrollment assistance. SHIPs provide one-on-one counseling to beneficiaries on complex Medicare-related topics, including Medicare entitlement and enrollment, health plan options, Medigap and long-term care insurance, the prescription drug benefit, and preventive benefits. SHIP funding will provide infrastructure, training, and outreach support to an expanded force of over 12,000 counselors in over 1,300 community-based organizations. CMS reports the following SHIP data:
     2006: 3.4 million clients served
     2007: 4.2 million served
     2008: not yet available

OTHER PROGRAMS
Home Energy Assistance. The FY 2010 Budget requests $3.2 billion for the Low-Income Home Energy Assistance Program (LIHEAP). This is the largest LIHEAP funding request for any year except the most recent when the Nation was threatened with an unprecedented increase in energy costs. The budget includes a legislative proposal to provide additional mandatory LIHEAP funding if energy prices increase.

National Institute on Aging. The National Institute on Aging would see its funding rise from $1.08 billion in FY 2009 to $1.09 billion in FY 2010, if the administration’s budget request is adopted by Congress.

The Social Services Block Grant would be level-funded at $1.7 billion.

Senior Community Service Employment. The Older Americans’ Act older worker program run by the Department of Labor would be cut from $692 milllion in FY 2009 to $575 mllion in FY 2010. The program did recently receive a $120-million boost from economic stimulus dollars.

Click here to see a table of key funding levels.

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AoA Creates New National Legal Resource Center to Enhance Legal and Aging Services
May 1, 2009

The Administration on Aging has awarded $825,000 to five national non-profit organizations to operate a new National Legal Resource Center (NLRC) to protect the rights, financial security, and independence of seniors most in need.

The NLRC will empower legal and aging services advocates with the resources necessary to provide high quality, free legal help to seniors who are facing direct threats to their ability to live independently in their homes and communities.

“For far too many older Americans, the economic challenges of today are becoming the legal problems of tomorrow," said HHS Secretary Kathleen Sebelius. "The National Legal Resource Center will ensure that our nation's aging and legal services networks have the tools they need to help those in our communities who are least able to advocate on their own behalf.”

The NLRC partner organizations are:
 The NLRC partners will provide intensive case consultation and specialized training on emerging legal issues that are adversely impacting the lives of seniors. With this vital support, advocates and professionals in aging and law will be able to serve senior consumers and clients more effectively. State offices on aging and local community-based aging organizations can also receive technical assistance in the efficient, cost-effective and targeted provision of legal services.

The NLRC will launch a new web site in November 2009 through which direct assistance and informational resources can be accessed.

More information on the National Legal Resource Center is available by contacting Omar.Valverde@aoa.hhs.gov.

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Obama Nominates Kathy Greenlee as Assistant Secretary for Aging
May 1, 2009

President Obama has nominated Kathy Greenlee as Assistant Secretary for the U.S. Administration on Aging.

Greenlee has served as Secretary of Aging for the state of Kansas since January 2006. In that capacity, she has led a cabinet-level agency with 192 full-time staff members and a total budget of $495 million.  Her department oversees the state’s Older Americans Act programs, the distribution of Medicaid long-term care payments and regulation of nursing home licensure and survey processes.

From 2004-2006, Greenlee served as State Long-Term Care Ombudsman in Kansas, and prior to that, was the state’s Assistant Secretary of Aging. From 1999-2002, Greenlee served as general counsel at the Kansas Insurance Department. During her tenure there, she led the team of regulators who evaluated the proposed sale of Blue Cross/Blue Shield of Kansas, and oversaw the Senior Health Insurance Counseling for Kansas program. Greenlee also served as Chief of Staff and Chief of Operations for Governor Kathleen Sebelius. She is a graduate of the University of Kansas with degrees in business administration and law.

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Better Drug Prescribing Is Focus of AGS Conference Session
April 30, 2009

Teaching medical students and residents how to more carefully prescribe medications for older adults can reduce the risk of hazardous drug interactions in this population. In a study presented at the American Geriatrics Society's (AGS) Annual Scientific Meeting, internal medicine residents at Johns Hopkins Bayview Medical Center completed an innovative 4-week curriculum designed to teach "thoughtful prescribing."

The curriculum emphasized drug interactions, complex drug regimens, the effects of drug costs on medication use, and related subjects. The main focus of the curriculum was a self-directed worksheet that prompted residents to review medication regimens for patients under their care during hospitalization, with attention to possible interactions, complex regimens, and cost, among other things. The residents had an introductory meeting with faculty to review the goals of the worksheet exercise, and one monthly session with a faculty member in which they shared and reflected on what they had learned.

After completing the program, 73% of the residents identified at least one instance in which the medications prescribed for a patient could cause an adverse drug interaction. And 22% identified at least one instance in which a potentially inappropriate medication had been prescribed for a patient over age 65. Residents participating in the program also expressed "surprise over the costs of drugs and an appreciation of the importance of considering the number of daily doses and necessity of looking up drug interactions," report lead author Lynsey Brandt, MD, PharmD, and colleagues at Johns Hopkins.

"Our findings show that a brief, self-directed tool can be utilized to increase residents' awareness of important principles of prescribing," said Dr. Brandt. "Although fundamentals of pharmacology are taught in medical school, it is during residency that one's prescribing practices are developed. Our hope is that by using a more deliberate approach to prescribing we can teach doctors habits that result in more safe and sensible care for their vulnerable patients."

In a second study, also presented at the American Geriatrics Society's annual meeting, medical students and residents at the Medical College of Wisconsin participated in an interactive program designed to raise awareness of issues surrounding polypharmacy -- the use of multiple drugs -- among the elderly. At the start of the program, the students completed questionnaires that included five statements and asked them to rate their knowledge and experience regarding each on a scale of one to six, where one indicated "no experience/knowledge" and six indicated "exceptional experience/knowledge". The five statements included: "I can identify barriers/solutions to medication adherence in my elderly patients," and "I routinely attempt to decrease the number/frequency of medications prescribed for my elderly patients."

Each student was then given the medication list of a patient recently cared for on his or her ward, and asked to follow it to fill a pill box with candy "medications." Students identified reasons this might be difficult for their patients - for example, due to, arthritis, vision loss, memory problems, or depression - and were then asked to take the "pills," as prescribed, for a week.

After the week was up, the students discussed their experiences with a faculty member, focusing on barriers that prevented them from taking their medications as prescribed. Barriers students mentioned included "too many medications," "medications that didn't seem helpful," and difficulty with the medication regimen. The students also discussed solutions that the physician and the patient and family could use to overcome these barriers. Possible solutions students mentioned included decreasing the number and dosing of medications, and asking a buddy to offer additional reminders to take medications, or using an alarm to do so.

Finally, students completed the questionnaire they'd filled out at the start of the program. This time they reported that their knowledge of barriers and solutions to medication adherence had increased substantially since the start of the program - with an average final score of 5, compared with an initial average score of 3. They also reported making more attempts to lower the number of medications and doses of medication they prescribed for their elderly patients.

In discussions with faculty members after they'd spent the week taking the candy "medications," the students reported "missing" many of the doses prescribed, and acknowledged the difficulty of adhering to a complex regimen. "This made me very aware of the difficulty in remembering to take meds," said one student. "If I have trouble with it as a healthy young adult, I can only imagine the difficulty my elderly, sick patients must have."

"This 'hands-on' experience really helps medical students and residents understand why their older patients may not be taking all of their medications as prescribed," said Kathryn Denson, MD, lead author of the study. "Walking in their patient's shoes helps them think practically about changes both the physician and patient can make to decrease medications and to help patients take their medications correctly."

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HHS Secretary: President Obama swore in Kansas Gov. Kathleen Sebelius (D) as secretary of the Department of Health and Human Services, following a Senate confirmation vote of 65-31.

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Swine Flu: The U.S. Department of Health and Human Services has issued a nationwide public health emergency declaration in response to recent human infections with newly discovered swine influenza A (swine flu) virus. The formal declaration of a Public Health Emergency (PHE) is a tool that facilitates HHS’ preparation and mobilization for disasters and emergencies.

The Administration on Aging is participating in daily calls with officials from the highest levels of government and closely monitoring the situation for how it might impact those we serve.  AoA will be keeping the national aging services network up to date.

For information on swine flu, visit http://www.cdc.gov/swineflu

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Poor Continuity of Care between Outpatient and Inpatient Settings
April 22, 2009

Fewer Medicare patients are seeing a familiar primary care or outpatient physician while they are in the hospital, according to a study in the April 22/29 issue of the Journal of the American Medical Association. About one-third of Medicare patients saw their primary care physician while hospitalized in 2006, while half received care from a physician they saw at least once as an outpatient in the prior year. That’s down from 44% and 40%, respectively, in 1996.

Greater decreases in continuity with outpatient physicians occurred in patients admitted on weekends, and those living in large metropolitan areas and in New England. About one-third of the decrease in continuity of care was associated with growth in hospitalists, which are general internal medicine physicians who primarily care for hospital patients. The findings are based on enrollment and claims data for a national sample of Medicare beneficiaries over age 66.

Continuity of care with an ongoing interaction of a patient with one physician “has shown to be associated with improved patient satisfaction, increased use of appropriate preventive health services, greater medication adherence, lower hospitalization rates, more appropriate end of life care, and lower cost," the authors wrote.

Patients with co-existing illnesses and the oldest patients were more likely to have continuity with their outpatient physicians and with their PCP during hospitalization.

"Future research should explore whether the lack of continuity contributes to suboptimal care and whether interventions might ameliorate any detrimental effects of discontinuities in care," the authors conclude.

(JAMA. 2009;301[16]:1671-1680)

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Boston College Launches National Resource Center for Participant-Directed Services
April 6, 2009

The Boston College Graduate School of Social Work has launched a new technical assistance center to give states tools to implement a wide variety of participant-directed long-term care programs. The National Resource Center for Participant-Directed Services is the first national center to assist states and other entities that want to offer, or already offer, participant-directed services to people with disabilities. Participant-directed (also called consumer-directed and self-directed) long-term care programs help people of all ages across all types of disabilities maintain their independence and determine for themselves what mix of personal care services and supports work best for them.
 
“The mission of the National Resource Center is to give every person eligible to receive publicly funded long-term care services and supports the option to manage those services for themselves at home,” said Kevin Mahoney, PhD, director of the new center and a professor at Boston College.
 
The National Resource Center for Participant-Directed Services will provide technical assistance, training, research, and policy analysis to states and other organizations with the goal of improving the lives of people of all ages with all types of disabilities who want to maintain their independence and freedom to direct their own services and supports. The center is funded by a $4.75 million grant from the Robert Wood Johnson Foundation, a $3.5 million grant from The Atlantic Philanthropies, and additional support from the U.S. Administration on Aging and the Office for the Assistant Secretary for Planning and Evaluation, and the Veterans Health Administration.
 
The National Resource Center builds on the lessons learned from the successful Cash & Counseling program (www.cashandcounseling.org), which has been implemented in 15 states. That program allows its participants to choose the type of services they receive, who provides those services and when, and to manage their own budgets to pay for the mix of goods and services that best meet their needs.

The new center can provide technical assistance to
The center will work closely with the National Participant Network, which brings together participants from different Cash & Counseling states to build involvement at the state level and provide feedback for program development and successful implementation of participant-directed services.
 
Services include:
 
Individual Consulting: The Center is staffed by a team of experts in participant-directed services. They are available to help states and other organizations design and implement participant-direction programs, evaluate existing programs, and/or recommend improvements in all aspects of participant-directed services, including: policy development, quality assurance, financial management support services, and program oversight.
 
Membership Program: Member benefits include updates on the latest developments in participant-direction, opportunities for peer-to-peer networking and support, and direct help with troubleshooting program problems and improving program operations.
 
Research:  The Center will manage a broad research agenda, including conducting research on promising practices in participant-direction and the impact of participant-directed programs. Research in the first year of operation will include an inventory of participant-direction programs nationwide.
 
Training: The Center will offer several training modules in different program areas, including helping states train the consultants who will help to administer their participant-direction programs. Additional modules are in development.
 
Public Policy: The Center will implement a public policy strategy that furthers research, knowledge, and understanding of self-direction for current and potential stakeholders.
 
Participant Involvement: The Center is committed to engaging and sustaining the involvement of participants with disabilities and their caregivers in the design, implementation, evaluation, improvement, and sustainability of participant-directed services. This includes developing plans and processes for helping both state programs and the Center involve participants at all programmatic levels.
 
Internet-Based Resources: The National Resource Center’s web site (www.participantdirection.org) will house a number of tools, including an online handbook written and edited by experts involved with the Cash & Counseling program. Developing and Implementing Self-Direction Programs and Policies: A Handbook will be a useful tool for all those working to develop or expand participant-direction programs. Chapters cover topics such as: legal authority, financial management services, individual budgeting, quality management, and involving program participants in design and implementation. The Handbook is now available for download online at www.cashandcounseling.org.
 
Go to: www.participantdirection.org.

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Medicare Announces Funding for State Health Insurance Counseling Programs for 2009
April 3, 2009

Nearly $36 million in funding is being distributed to the 54 State Health Insurance Assistance Programs (SHIPs) to help people with Medicare get more information about their health care choices. The funding is the first installment of federal grant funds provided to SHIPs by the Centers for Medicare & Medicaid Services (CMS) for the grant year beginning April 1, 2009, and ending March 31, 2010.

An additional $1.5 million in performance-based funding will be awarded in September 2009.

SHIPs are state-based programs that use community-based networks to provide Medicare beneficiaries with local, personalized assistance on a wide variety of Medicare and health insurance topics. 

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Good Intentions Not Enough To Protect Older Women Who Live Alone, Research Shows
March 31, 2009

Older women who live alone are vulnerable to unwanted intrusions in their homes, according to the Centers for Disease Control and Prevention. Caregivers of older women often evaluate crime risk and home security, but fail to identify women's intentions to reduce intrusion risk. In a new study, a University of Missouri professor has found that in order to feel safe at home, older women need to recognize safety risks and perceive themselves as capable of preventing intrusions.

"Older women's intentions to ensure accessibility to their homes for family, friends, and neighbors can override their concerns about preventing intrusions," said Eileen Porter, professor in the Sinclair School of Nursing. "Health care providers need to engage older women in conversations about the risks they perceive and their intentions to reduce those risks."

Previously, researchers had not evaluated the use of intention as a component of home safety assessments. The findings of this study reveal the need for safety interventions to supplement basic safety tips, Porter said.

"To ensure that older people avoid victimization at home, health care providers often focus on providing recommendations such as locking the doors and installing security systems," Porter said. "However, it is not enough to ask if they are locking their doors, because the meaning of that term varies among people. Some women, who affirm that they are 'locking the door,' are locking their front door at night and during certain seasons of the year, but otherwise leaving front and back doors unlocked."

Older homebound women who express worry about intrusions can benefit from carrying a portable phone or subscribing to a personal emergency response system, Porter said. Women who own portable phones but do not carry them can benefit from conversations about why they choose not to carry phones and questions about how they would reach help quickly if possible situations arise.

"Caregivers and nurses should develop individualized safety interventions based on older women's intentions to protect themselves and reduce intrusion risks," Porter said. "Nurses should conduct multiple interviews and ask questions about safety perceptions, potential reasons for reaching help quickly and how to reach help immediately."

Porter interviewed 40 homebound women, ages 85 to 95 and living alone, about their perceptions of feeling safe at home and precautions to protect themselves. The women reported various intentions about reducing intrusion risk, perceived capabilities in intrusion situations, and frequency of carrying devices that enable them to reach help quickly. Their main intentions to reduce risks at home were keeping watch, keeping out of harm's way, preventing theft and vandalism, discouraging people who might want to get in, and keeping those people out. Porter says these issues are important to consider when developing assessment questions and safety interventions.

The study, "Reducing My Risk of Intrusion, An Intention of Old Homebound Women Living Alone," was published in October, 2008 in Nursing Research. The study, "Contemplating What I Would Do If Someone Got in My House, Intentions of Older Homebound Women Living Alone," was published in 2008 in Advances in Nursing Science. The studies were funded by a grant from the U.S. National Institutes of Health National Institute on Aging.

Source: University of Missouri-Columbia/EurekaAlert

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Caregiver Health Growing Concern for CDC, Public Health Community
March 23, 2009

While unpaid caregivers often say they get satisfaction from their efforts to care for aging family members and friends, caregiving can be stressful and burdensome and can contribute to depression and eventually to negative health effects for the caregiver, according to researcher Richard Schulz, PhD, Professor of Psychiatry at the University of Pittsburgh School of Medicine.

In addition to the stress or strain that caregivers face, they often avoid getting routine care for their own health and may have an impaired ability to recover from an illness, said John Crews, DPA, an epidemiologist at the U.S. Centers for Disease Control and Prevention (CDC). A decline in the caregiver’s health often leads to institutionalization of the care recipient. The chronic health impact of caregiving on health may last longer than the caregiving itself.
(Click here to view rest of story)

This article was adapted from the latest Critical Issue Brief released by the CDC Healthy Aging Program at the American Society on Aging/ National Council on Aging annual conference held in Las Vegas in March. It will be posted online shortly.

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Researchers Report Possible Malnutrition among Older Adults
March 1, 2009

Deficits in micronutrients may be contributing to poor nutrition and health in older adults as they age. There is concern that deficits in micronutrients such as calcium, magnesium, potassium and Vitamin C lead to medical problems, according to a study by Pamela Schreiner, Professor and Director of Graduate Studies, Division of Epidemiology and Community Health, University of Minnesota, et al.

Low intake of nutrients is associated with poor health outcomes. The study examined the contribution of dietary supplementation to meeting recommended dietary intakes of calcium, magnesium, potassium, and vitamin C in participants of the Multi-Ethnic Study of Atherosclerosis, a cohort of white, African-American, Hispanic, and Chinese-American participants ages 45 to 84 years.

Although supplement use is associated with meeting Dietary Reference Intake (DRI) guidelines for calcium, vitamin C and magnesium, many adults are not meeting the DRI guidelines even with the help of dietary supplements, and the effect of supplementation can vary according to ethnicity and sex, the researchers reported. However, supplementation was not significantly associated with meeting DRIs for potassium. Also, high-dose supplement use is associated with intakes above Tolerable Upper Intake Levels for calcium, magnesium, and vitamin C.

The research was published in the March 2009 issue of the Journal of the American Dietetic Association Volume 109, Issue 3.

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Senate Action Pending on FY 2009 Omnibus Appropriations Bill
February 25, 2009; Signed into law.

The House approved a FY 2009 omnibus spending package for the Department of Health and Human Services and other federal agencies on a 245-178 vote. FY 2009 began Oct. 1, 2008, and the agency is currently operating under a continuing resolution that expires March 6. The Senate is expected to take up the package next week.

The appropriations bill (H.R. 1105) provides $66.3 billion in discretionary funding for HHS programs, a 3% increase from the current level. The FY09 Omnibus Appropriations bill includes funding for:

Lifespan Respite: $2.5 million to support coordinated systems of community-based respite care services for family caregivers of children and adults with special needs.

Real Choice Systems Change Grants to States: $5 million.

State Health Insurance Program: $45 million. It also directs that the next publication of "Medicare & You" include information on advance directives and living wills.

Medicare Fraud and Abuse Control: $198 million, including funds to expand CMS efforts to link Medicare claims and public records data and to initiate new demonstration projects using data mining technologies.

Geriatric education: $31 milion.

Title VIII Nursing Workforce Development Programs: $171 million.

Low-Income Home Energy Assistance: no funding. Public Law 110-329, the Consolidated Security, Disaster Assistance, and Continuing Appropriations Act, 2009, provided fiscal year 2009 funding of $5.1 billion for LIHEAP, which is $2,529,672,000 above the fiscal year 2008 level and $3,100,000,000 over the budget request. As a result, this bill does not include funding for LIHEAP.

Social Services Block Grant: $1.7 billion, which is the same as the fiscal year 2008 level.

Older Americans Act
Older Workers: $571.9 million for Community Service Employment for Older Americans, which is $50 million above the FY 2008 funding level and $221.9 million above the budget request. New bill language will allow for these funds to be recaptured and reobligated in accordance with section 517(c) of the Older Americans Act.

Protection of Vulnerable Older Americans: $21,383,000, which includes:
 Title IV Program Innovations: $18.2 million. Funding is provided at no less than the fiscal year 2008 levels for national programs scheduled to be refunded in fiscal year 2009. Within these funds, the bill includes:
 Aging Network Support Activities: $41.7 million, including:  The bill does not provide funding for the National Center on Senior Benefits Outreach and Enrollment. Section 119 of P.L. 110-275, the Medicare Improvements for Patients and Providers Act of 2008, provided $17,500,000 to the AoA for Medicare enrollment assistance, including $5,000,000 specifically to inform seniors about benefits available under existing federal and state programs. Bill language has been included to allow the AoA to administer these funds.

Click here to view table of appropriations showing FY 2008 and FY 2009 comparisons.

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LIHEAP, NIH Cancer Research Among Few Budget Items with Specified Dollars
Feb. 26, 2009

President Obama’s first budget proposal is an outline of goals and directions, with only a few expenditures detailed at this point. A more complete budget is expected later.

The budget request seeks $3.2 billion for the Low-Income Home Energy Assistance Program (LIHEAP) to help low-income families with their home heating and cooling expenses. That is the highest level of LIHEAP funding for any year except for the most recent. It also proposes creating a new trigger mechanism to provide automatic increases in energy assistance whenever there is a spike in energy costs. The normal appropriations process cannot always respond to the volatile energy market on a timely basis; the trigger will ensure a prompt and potentially significant increase in funds in response to a rapid future rise in costs.

The budget proposes to invest over $6 billion for cancer research at the National Institutes of Health as part of the administration’s multi-year commitment to double cancer research funding.

There are no specifics at this point for Older Americans Act programs or the Social Services Block Grant.

Medicare Integrity. The administration intends to strengthen the Medicare program by encouraging high quality and efficient care, and improving program integrity. The budget proposes to dedicate additional resources that will initially be targeted to improving oversight and program integrity activities for the Medicare Prescription Drug Program (Part D), Medicare Advantage, and the Medicaid Program. These resources will enable the Centers for Medicare and Medicaid Services to more rapidly respond to emerging program integrity vulnerabilities, identify excessive payments, and establish new processes for correcting problems. As a result, the administration said it will be better able to minimize inappropriate payments, close loopholes, and provide greater value for program expenditures to beneficiaries and taxpayers.

Medicare and Medicaid Research Agenda. The budget includes new funding to broaden the Medicare and Medicaid research agenda. The expanded agenda will take advantage of the robust data available for these programs. New Medicare and Medicaid demonstration and pilot projects will evaluate payment reforms, ways to provide higher quality care at lower costs, improve beneficiary education and understanding of benefits offered, and better align provider payments with costs.

Health Information Technology. The administration said it will continue efforts to further the adoption and implementation of health IT—an essential tool to modernize the health care system. The economic recovery act offers physicians and hospitals participating in the Medicare program temporary incentive payments starting in 2011 for using a certified electronic health record, followed by financial penalties starting in 2015 for failure to use such a system.  Computerizing health records—while protecting the privacy and security of personal health information—are expected to facilitate improvements in the quality of health care, prevention of unnecessary health care spending, and a reduction in medical errors.

Corporation for National and Community Service. The president proposes to engage more retiring Americans in service, harnessing their skills and knowledge. The budget proposal would expand and improve Senior Corps programs, which connect individuals over the age of 55 to local volunteer opportunities, allowing more retirees to help meet the needs and challenges in their communities. The administration proposes $1.13 billion for CNCS, an increase of $261 million from the 2009 likely enacted level.

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Stimulus Bill Includes $100 Million for Senior Nutrition; $650 Million for Health Promotion
Feb. 13, 2009

The American Recovery and Reinvestment Act of 2009 (H.R. 1), known as the economic stimulus bill, contains $100 million for the senior meals program, including $65 million for congregate meals, $32 million for home-delivered meals, and $3 million for Native American nutrition services provided under the Older Americans Act. The conference committee did not go along with the Senate request to provide $200 million instead of $100 million. The House has approved the bill and the Senate is expected to do so shortly.

The measure also contains $120 million for the Older Americans Act Title V older worker program. The economic recovery funds are to be distributed to current grantees to support additional employment opportunities for low income seniors. The wages paid to these low-income seniors will provide a direct stimulus to the economies of local communities, which will also benefit from the community service work performed by participants. The conference agreement includes language to allow for the recapture and reobligation of such funds, as proposed by the Senate and as authorized under Title V of the Older Americans Act.

The bill also includes $20 billion for the Food Stamp Program (now called the Supplemental Nutrition Assistance Program).

The measure contains $650 million to carry out evidence-based clinical and community-based prevention and wellness strategies authorized by the Public Health Service Act to deliver specific, measurable health outcomes that address chronic disease rates. However, up to 0.5% of the funds may be used for management and oversight expenses, and the Secretary of Department of Health and Human Services may choose to move some funds to other appropriations accounts.

The measure includes $87 billion for a temporary increase in the share of the Medicaid program paid by the federal government, known as the Federal Medicaid match rate (FMAP). States will receive the FMAP funds over a 27-month period started in October 2008 and ending Dec. 31, 2010. For an analysis by the Center on Budget and Policy Priorities, go to: http://www.cbpp.org/1-22-09bud-fmap.pdf.

The conference agreement includes $10 billion for the National Institutes of Health (NIH) to conduct biomedical research in areas such as cancer, Alzheimer’s, heart disease and stem cells, and to improve NIH facilities

Department of Education funding includes a $34.3 million for Services for Older Blind Individuals.

Despite Senate action to provide $400 million for the Social Services Block Grant, the final product did not contain any money for SSBG. It also did not include funds for the Low-Income Home Energy Assistance Program.

The measure would require the HHS Secretary, within two years and annually thereafter, to report to Congress on efforts to facilitate the adoption of a nationwide system for the electronic exchange of health information; to conduct a study, not later than two years after enactment, that examines methods to create efficient reimbursement incentives for improving health care quality in federally qualified health centers, rural health clinical and free clinics; and to conduct a study, not later than 24 months after enactment, of matters relating to the potential use of new aging services technology to assist seniors; individuals with disabilities and their caregivers throughout the aging process.

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Center Says 22 States Cutting Elder/Disability Services
Feb. 10, 2009

According to the Center on Budget and Policy Priorities, at least 22 states and the District of Columbia are reducing or proposing to cut services for older adults and persons with disabilities in light of their budget deficits. These cuts include medical, rehabilitative, home care, or other services needed by low-income people who are elderly or have disabilities, or significantly increasing the cost of these services.

For example, Florida has frozen reimbursements to nursing homes and relaxed staffing standards, Nevada is making it harder for beneficiaries to qualify for nursing home care, and Rhode Island is requiring low-income elderly people to pay more for adult daycare. Arizona eliminated temporary health insurance for people with serious medical problems.

According to the report:

In Alabama, the Department of Human Resources has ended home-makers services for approximately 1,100 older adults. These services often allow people to stay in their own homes and avoid nursing home care.

In Georgia, services for the elderly, such as Alzheimer services, elder service centers, prescription drug assistance, and elder support services, have been reduced

In Massachusetts, the Governor has ordered spending cuts for programs for elders, including home care, geriatric mental health services, and prescription drug assistance.

In Nevada, state officials are considering making it harder for poor adults to qualify for needed nursing home care and extending existing limits on personal-care services for elderly and disabled Medicaid beneficiaries who need help with bathing and dressing. More than 5,000 low-income Nevadans would be affected by this change.

New York’s governor has proposed cutting the state’s Supplementary Security Income (SSI)
supplement. This would reduce monthly state supplemental payments provided to low-income
recipients who are elderly, blind, or disabled by between $16 and $28 through December, 2009.
After December 2009 supplemental payments would increase slightly but would still remain
below current levels.

In Rhode Island, low-income elderly people now must pay higher rates for subsidized adult daycare. This is estimated to affect more than 1,200 people with incomes below $20,000.

Vermont has reduced some home-based services, such as housekeeping and shopping, for people who are elderly or disabled. Such services help pay stay in their own homes and possibly delay or avoid more expensive nursing home care.

A total of 40 states have made or proposed budget cuts that threaten vital services for many residents. “These budget cuts are worsening the recession because they reduce overall economic activity and take money out of local economies,” the authors state.

Click here to view the full report

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Coordinated Medicare for Chronic Illnesses Does Not Show Benefit
Feb. 10, 2009

Only 2 of 15 Medicare programs designed to improve care and costs for patients with chronic illnesses resulted in reduced hospital admissions, and none of the programs generated net savings, according to a study in the February 11 issue of JAMA.

Chronic illnesses pose a significant expense to the Medicare program. The high expenditures generated by these beneficiaries are driven primarily by hospital admissions and readmissions, according to background information in the article. Several factors appear to contribute to the high rate of hospitalizations, including patients receiving inadequate counseling on diet, medication, and self-care; not having ready access to medical help other than the emergency department; and poor communication betweens patients and physicians. Some studies have suggested that interventions to address the barriers faced by chronically ill patients could reduce avoidable hospitalizations and decrease Medicare expenditures.

The Centers for Medicare & Medicaid Services (CMS) in 2002 competitively awarded 15 demonstration programs to various health care programs. Deborah Peikes, Ph.D., and colleagues from the Mathematica Policy Research Inc., Princeton, N.J., analyzed the results from randomized controlled trials of these 15 programs on how they affected Medicare expenditures and quality of care. The programs included eligible fee-for-service Medicare patients (primarily with congestive heart failure, coronary artery disease, and diabetes) who volunteered to participate between April 2002 and June 2005 and were randomly assigned to treatment or control (usual care).

Hospitalizations, Medicare expenditures and some quality-of-care outcomes were measured with claims data for 18,309 patients.

The researchers found that 13 of the 15 programs showed no significant differences in hospitalizations. Mercy Medical Center, in northwestern Iowa, significantly reduced hospitalizations by 17%, and Charlestown retirement community in Maryland had an increase of 19% more hospitalizations.

None of the programs reduced regular Medicare expenditures. Treatment group members in 3 programs (Health Quality Partners [HQP, in Pa.], Georgetown, [a medical center in Washington, D.C.] and Mercy) had monthly Medicare expenditures less than the control group by 9% to 14%. Savings offset fees for HQP and Georgetown but not for Mercy; Georgetown was too small to be sustainable. For total Medicare expenditures including program fees, the treatment groups for 9 programs had 8% to 41% higher total expenditures than the control groups did, all statistically significant.

For the survey-based outcomes-of-care measures, despite reporting much higher rates of being taught self-management skills, treatment group members were no more likely than control group members to say they understood proper diet and exercise, or to state that they were adhering to prescribed or recommended diet, exercise, and medications.

The authors add that a comparison of the two programs with the most positive results with the other programs indicates there were a number of noteworthy differences, including higher rates of in-person contact per month per patient; treatment group members were significantly more likely than control group members to report being taught how to take their medications; care coordinators for both HQP and Mercy worked closely with local hospitals, which provided the programs with timely information on patient hospitalizations and improved their potential to manage transitions and reduce short-term readmissions; and care coordinators in both programs had frequent opportunities to interact informally with physicians.

"Despite these underwhelming results for care coordination interventions in general, the favorable findings for Mercy and HQP suggest that the potential exists for care coordination interventions to be cost-neutral and to improve patients' well-being," the researchers write.

The findings are published in JAMA. 2009;301[6]:603-618.

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New Diagnoses May Provide Window of Opportunity for Health Behavior Change
Feb. 9, 2009

Older adults appear more likely to quit smoking or lose weight following a recent diagnosis of heart disease, diabetes or another serious condition, according to a report in the February 9 issue of Archives of Internal Medicine, one of the JAMA/Archives journals.

“Smoking and patterns of diet and activity are the two leading underlying causes of death in the United States, yet the factors that prompt individuals to adopt healthier habits are not well understood,” the author wrote as background information in the article. One-fifth of U.S. adults older than 25 smoke, and two-thirds of adults age 20 to 75 years are overweight or obese. Clinical guidelines recommend weight loss and smoking cessation to prevent health risks in these individuals, and advise physicians to counsel their patients about these options.

Patricia S. Keenan, Ph.D., M.H.S., of Yale School of Medicine and Yale School of Public Health, New Haven, Conn., analyzed data from the Health and Retirement Study, a survey of middle-aged and older adults. Participants were first surveyed in 1992 and subsequent surveys have been conducted every other year. A total of 20,221 overweight or obese individuals younger than 75 years and 7,764 smokers were surveyed at least twice between 1992 and 2000.

“Targeting individuals with recent new diagnoses may be particularly effective in middle-aged and older individuals, who are increasingly likely to receive a major diagnosis or to be hospitalized as they age,” she continues. “Individuals with new adverse health events are accessible through contact with the health care system or through the Internet or other written information about their disease, and this study suggests that they are more motivated to change health habits.”

Over the course of the surveys, 18% of smokers quit and average body mass index increased by 0.04 units in the overweight and obese group. About 13% of smokers were diagnosed with stroke, cancer, lung disease, heart disease or diabetes, while 8% of overweight or obese individuals received a diagnosis of lung disease, heart disease or diabetes.
 
“Individuals with new diagnoses were more likely to adopt healthier habits than those without recent new diagnoses,” Dr. Keenan writes. Smokers had 3.2 times the odds of quitting if they had received at least one of the five diagnoses vs. no new diagnoses. The overweight or obese individuals who were diagnosed with lung disease, heart disease or diabetes lost an average of 2 to 3 pounds more than those who were not diagnosed with any of these conditions.

Multiple diagnoses were associated with a greater magnitude of behavior change—compared with smokers who received no new diagnoses, those with one diagnosis had 2.9 times greater odds of quitting and those with multiple new diagnoses had 6.1 times greater odds of quitting. Overweight or obese individuals with one new diagnosis decreased their body mass index (BMI) by an average of 0.34 units, while those with more than one diagnosis lost an average of 0.64 units.

This study was supported by grants from the National Institute on Aging. The findings are in the Arch Intern Med. 2009;169[3]:237-242.

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Tests may predict driving safety in people with Alzheimer's disease
Feb. 9, 2009

Doctors may be able to use certain cognitive tests to help determine whether a person with Alzheimer's disease can safely get behind the wheel. The research is published in the February 10, 2009, issue of Neurology, the medical journal of the American Academy of Neurology.

"The number of people with dementia is increasing as our population ages, and we will face a growing public health problem of elderly drivers with memory loss," says study author Jeffrey Dawson, ScD, with the University of Iowa in Iowa City.

In the study, 40 drivers with early Alzheimer's disease and 115 elderly drivers without this diagnosis underwent a combination of off-road tests that measured thinking, movement and visual skills. The participants also drove a 35-mile route in and outside the city. Driving safety errors were recorded by a driving expert, based on a video review of the drive.

The research found drivers with Alzheimer's disease committed an average of 42 safety mistakes, or 27% more than the drivers without Alzheimer's disease, who made an average of 33 safety errors on the test drive. The most common mistakes were lane violations. For every five years older the participant was, the number of safety errors went up by about two and a half, whether or not they had Alzheimer's disease.

Among drivers with Alzheimer's disease, those who performed better on the off-road tests made fewer on-road safety errors.

"The goal is to prevent crashes while still maximizing patients' rights and freedom to be mobile," said Dawson. "By measuring driver performance through off-road tests of memory, visual and motor abilities, we may be able to develop a standardized assessment of a person's fitness to drive."

The study was supported by the National Institute on Aging.

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Reports Examine Economic Burden of Health Care Costs on Medicare Beneficiaries
Feb. 4, 2009

Kaiser Family Foundation researchers report that Medicare beneficiaries’ out-of-pocket health care costs comprise a significant share of their household expenses.

In 2006, out-of-pocket health care spending accounted for 14.1% of all expenditures for Medicare households –- less than housing but about the same as transportation and food. One in four Medicare households devotes more than one quarter of total household expenditures to health care. This group includes a disproportionate share of Medicare households that are low- and middle-income, have older members and are living in rural areas. The report is based on analysis of data from the 2006 Consumer Expenditure Survey. The new report is Health Care on a Budget: An Analysis of Spending by Medicare Households.

A second report, Revisiting ‘Skin in the Game’ Among Medicare Beneficiaries, a data update, finds the financial burden of out-of-pocket health care spending by Medicare beneficiaries increasing between 1997 and 2005. During this nine-year period, median out-of-pocket spending as a share of income for people on Medicare climbed to 16.1% in 2005, up from 15.6% in 2004 and 11.9% in 1997. For some beneficiaries, the spending burden was even greater, with 25% of people on Medicare spending nearly one-third or more of their income on health care. The analysis does not capture the effects of the Medicare Part D drug benefit, which began in 2006, because the data are not yet available.

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Seniors in Medicare's Doughnut Hole Decrease Use of Meds
Feb. 3, 2009

Beneficiaries enrolled in Medicare Part D who reached a gap in health care coverage known as the "doughnut hole" were much less likely to use prescription drugs than those with an employer-based plan, according to a University of Pittsburgh Graduate School of Public Health study. The findings, published in the Feb. 3 online issue of Health Affairs, raise concerns about health consequences and increased costs from hospitalizations and physician visits that may arise from lack of coverage. To protect seniors, the authors suggest a change in policy that would mandate the coverage of generic drugs in the doughnut hole through a modest increase in initial prescription co-pays.

The study also found that Medicare beneficiaries with diabetes were more likely to reach the doughnut hole than those with hypertension, and they reached it sooner. Those with more than one chronic illness also were much more likely to reach the doughnut hole – 34% with both hypertension and diabetes reached it, and 61% of those with hypertension, hyperlipidemia, congestive heart failure and diabetes did so.

A controversial aspect of Medicare Part D is the doughnut hole, a gap in coverage of prescription drugs that in 2006 occurred when annual individual drug expenditures reached $2,250. Lead author Yuting Zhang, Ph.D., assistant professor of health economics at the University of Pittsburgh Graduate School of Public Health, and colleagues compared two groups of senior citizens with Medicare drug coverage provided by a large Pennsylvania insurer in 2006. One group was covered through more generous employer-sponsored plans with full coverage in the doughnut hole and the other was covered through Medicare Advantage prescription drug plans (MA-PD) with either no doughnut hole drug coverage or generic coverage only.

They found that one in four (25%) of Pennsylvanians enrolled in an MA-PD reached the doughnut hole, but only one in 20 (5%) of that subset of individuals went on to reach the catastrophic phase of coverage – when annual drug spending reached $5,100 and Part D coverage of drugs resumed.

In addition, Medicare beneficiaries who lacked coverage in the doughnut hole reduced their monthly prescriptions by 14% per month once they entered the doughnut hole. Those with generic coverage in the doughnut hole decreased their monthly prescriptions by only 3%, and those who were enrolled in employer-based plans had no changes in monthly prescriptions when they reached the doughnut hole spending level.

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Older Adults with Osteoporotic Fracture Have Increased Risk of Death for 5-10 Years
Feb. 3, 2009

Women and men age 60 years or older who have a low-trauma osteoporotic fracture have an increased risk of death for the following 5 to 10 years, compared to the general population, and those who experience another fracture increase their risk of death further for an additional 5 years, according to a study in the February 4 issue of JAMA.

Osteoporotic fractures represent a growing public health problem in both developed and developing countries, with a projected increasing incidence as the population ages. There are limited data on the long-term risk of death following osteoporotic fracture or a subsequent fracture, according to background information in the article.

Dana Bliuc, M.Med., of the Garvan Institute of Medical Research, St. Vincent's Hospital, Sydney, Australia, and colleagues examined the long-term risk of death (up to 18 years) following all types of osteoporotic fractures in women and men in different age groups and the association of subsequent fracture with mortality risk. The study included women and men age 60 years and older from Dubbo, Australia. In women, there were 952 low-trauma fractures followed by 461 deaths, and in men, 343 fractures were followed by 197 deaths.

In comparison to the general population, increased mortality risk was observed across all age groups following hip, vertebral, and major fractures for 5 years post-fracture except for minor fractures, where an increased risk of death was only apparent in those age 75 years or older. After five years, the mortality risk decreased, with hip fracture–associated mortality remaining elevated for up to 10 years. After 10 years, mortality rates were not different from that of an appropriately age-matched population.

"Nonhip, nonvertebral fractures, generally not considered in these types of studies, not only constituted almost 50% of the fractures studied, but also were associated with 29 percent of the premature mortality. Mortality risk decreased with time; however, the occurrence of a subsequent fracture was associated with a 3- to 4-fold increased mortality risk for a further 5 years," the authors write. "Given these findings, more attention should be given to nonhip, nonvertebral fractures …"

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AcademyHealth Awards Cash and Counseling Evaluator
Feb. 3, 2009

The AcademyHealth Board of Directors has issued its HSR Impact Award to Randall S. Brown, vice president and director of health research at Mathematica Policy Research in Princeton, NJ. The award recognizes research that has had a significant impact on health and health care.

Over the past 25 years, Dr. Brown has designed and led evaluations of some of the nation's largest demonstration programs in both care coordination and long-term care. In the long term-care area, he led the evaluation of the Cash and Counseling Demonstration, and currently is principal investigator for the Money Follows the Person program evaluation. His work on care coordination and disease management includes leading two recent evaluations of demonstrations funded by the Centers for Medicare & Medicaid Services, resulting in four reports to Congress on these programs' effects on service use, costs, quality of care, and patients' and physicians' satisfaction with care. He is currently leading several ongoing studies of these programs to develop lessons about how to improve outcomes for Medicare beneficiaries with chronic illnesses. His earlier work includes leading large-scale evaluations of the Medicare managed care program and the expansion of Medicaid benefits to low-income families, a report to congress on the Social HMO program, and the National Channeling Demonstration, an early test of whether case management and flexible use of federal dollars could reduce nursing home dependence.

Cash & counseling is funded by the Robert Wood Johnson Foundation. It offers Medicaid consumers with disabilities choices for obtaining help at home. The program provides a flexible monthly allowance based on an individualized budget, allowing consumers to directly manage personal assistance services and address their specific needs. In addition, this program offers counseling and fiscal assistance to help consumers personally manage their allowance and responsibilities. The Robert Wood Johnson Foundation and the Office of the Assistant Secretary for Planning and Evaluation at the U.S. Department of Health and Human Services jointly funded this evaluation and demonstration in Arkansas, New Jersey and Florida.
View article on winner

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Economic Stimulus Bill Includes Funding for Aging Programs
Feb. 1, 2009

The economic stimulus bills pending before Congress include several provisions that would increase funding for aging services programs.

Senior Community Service Employment Program (SCSEP) -- An additional $120 million to create 24,000 jobs.

Senior Nutrition -- Additional funding for senior nutrition programs (congregate and home-delivered meals). The House bill provides twice the funding for senior nutrition ($200 million) as the Senate bill.

Medicaid Match Rate -- An additional $88 billion to increase the federal Medicaid match rate (FMAP) to provide temporary relief to states.

Supplemental Security Income -- An additional $4.2 billion for a one-time additional Supplemental Security Income (SSI) payment (an average of $450 for an individual and $630 for a couple).

Prevention and Wellness Fund -- $3 billion to for health promotion and disease prevention activities. The House bill has $50 million for injury prevention, including fall prevention. Advocates argued for some of the money to be set aside for the Administration on Aging, but there is no specific set-aside at this point. The Senate version does include non-binding support for AoA evidence-based programs.

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Decline In Health Among Older Adults Affected By Hurricane Katrina
Jan. 22, 2009

In the year following Hurricane Katrina, the health of survivors 65 and over declined nearly 4 times that of a national sample of older adults not affected by the disaster, according to a study led by researchers at the Johns Hopkins Bloomberg School of Public Health. Researchers monitored enrollees of a New Orleans-area managed care organization and found morbidity rates increased 12.6 percent compared with 3.4 percent nationwide. The results are published in the January issue of “The American Journal of Managed Care.”

In the year following Hurricane Katrina, morbidity rates increased substantially," said Lynda Burton, ScD, lead author of the study and adjunct associate professor with the Bloomberg School's Department of Health Policy and Management. "Morbidity rates among non-white Orleans residents were the highest when compared to other parishes and there was a significant increase in the prevalence of patients with cardiac diagnoses, congestive heart failure and sleep problems. Survivors displaced out-of-state experienced higher morbidity rates than those not displaced. In the month following the disaster, mortality spiked, but during the remainder of the year returned to a level consistent with the previous year."

Researchers examined the managed care organization claims of 20,612 white and non-white residents of Orleans, Jefferson, St. Tammany and Plaquemines parishes who were over the age of 65 and enrolled in Peoples Health, a provider-owned managed care organization.

The researchers found that emergency department visits increased 100% in the month following Katrina, and by 21% over the next year compared to the pre-Katrina year. Hospitalization rates increased 66% in the first month after Katrina and maintained an increase of 23% over the ensuing year.

Researchers believe displacement played a major role in health outcomes. Sixty-nine percent reported moderate or severe damage to their home, or that their home was destroyed. At the end of the year, 28% reported their residence remained unlivable and another 28% reported a worse financial situation.

"The enormous health burden experienced by older individuals and the disruptions in service utilization reveal the long-term effects of Hurricane Katrina on this vulnerable population," said Jonathan Weiner, DrPH, senior author of the study and director of the Bloomberg School's PhD Program in Health Services Research and Policy. "Although quick rebuilding of the provider network may have attenuated more severe health outcomes for this managed care population, new policies must be introduced to deal with the health consequences of a major disaster."

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