Tuesday, January 17, 2012

Caring for Your Mom at Home

A woman from my hometown recently sent me an email with this question:

My mom is now living with us and someone said you might be able to tell me the names of some books to read.  She is having trouble remembering things, things that happened just a day ago. It is not just once in a while, it is all the time. She can't remember her grandson's names...it is killing me to see her this way.  Everyone tells me to just agree with her and don't tell her any different....but you know me, I need to tell her the right thing. Like if she says....he gave me the two pairs of slippers....I will say, No, Mom, he gave you the blue ones and the pink ones are from me. I want her to try and remember and by telling her, she says oh, yes, I remember. Am I wrong?

So, your mom is living with you now. That is quite an adjustment, but I'm glad she's in a loving home with family. Sounds like she is having some short-term memory problems, or dementia, and this could be caused by a lot of different things. To learn more about dementia, I recommend the 36 Hour Day. It's a great book for families facing dementia for the first time.

Most folks in the elder care world do suggest "meeting a person where he/she is," in other words, just go along with them and with whatever they believe as long as they are not harming themselves or others. Since your mom will likely not be able to recover the ability to remember events or people, correcting her will only make her feel bad and ashamed, or get agitated. So, you just smile and nod when she says that the cows are in the front yard eating blue hay. This can be difficult and very trying for family members, especially when you are living with it 24/7, so I recommend getting support from others. The Alzheimer's Association has some great recommendations on their website www.alz.org including a list of support groups that meet monthly. I strongly recommend connecting with others that are going through this; their insight and experience will be invaluable.

The other book I would recommend is the AARP's Caring for Your Parents.  And here is a blog that I really enjoy http://newoldage.blogs.nytimes.com/

I hope some of this helps.  Caring for a loved one at home can be difficult. Finding support from others will be helpful as you make this journey. 

Thursday, January 12, 2012

Raising the Eligibilty Age for Medicare and SS?

I just caught wind of this discussion, and I'm afraid this could become a reality.

The CBO just released its "research" that supports raising the Medicare and SS eligibility age:

The report indicates that more people will have to work longer--did they realize it's especially hard for those in their 60s to find jobs? (see: www.pewtrusts.org/uploadedFiles/wwwpewtrustsorg/Reports/Fiscal_Analysis/Long-term-unemployment-addendum-November-2011.pdf

The report claimed that about 5% of those using Medicare would be uninsured but that most would get insurance from the private sector (Really--who's underwriting folks in their 60s and offering affordable premiums? The ACA has charged states with creating health insurance exchanges, but those are being challenged and states like Georgia are sitting on their hands waiting for it to be repealed: http://www.ajc.com/news/georgia-politics-elections/waiting-game-may-cost-1291709.html ) or from their spouse's employers (sorry same-sex couples, entrepreneurs, and single/widowed folks).  Here is a quote from the report:

CBO assumed that people who became ineligible for Medicare under the new age limits could purchase health insurance through the exchanges, and, depending on their income, might qualify for federal subsidies. CBO also assumed that people with the lowest income would qualify for Medicaid benefits. Without those changes to the recently enacted health care laws, CBO anticipates many more people would become uninsured if the MEA was raised.

Compare that to Robert Reich's thoughts (found at http://robertreich.org/post/7941066493):

So what’s the answer? For starters, allow anyone at any age to join Medicare. Medicare’s administrative costs are in the range of 3 percent. That’s well below the 5 to 10 percent costs borne by large companies that self-insure. It’s even further below the administrative costs of companies in the small-group market (amounting to 25 to 27 percent of premiums). And it’s way, way lower than the administrative costs of individual insurance (40 percent). It’s even far below the 11 percent costs of private plans under Medicare Advantage, the current private-insurance option under Medicare.
In addition, allow Medicare – and its poor cousin Medicaid – to use their huge bargaining leverage to negotiate lower rates with hospitals, doctors, and pharmaceutical companies. This would help move health care from a fee-for-the-most-costly-service system into one designed to get the highest-quality outcomes most cheaply.
Estimates of how much would be saved by extending Medicare to cover the entire population range from $58 billion to $400 billion a year. More Americans would get quality health care, and the long-term budget crisis would be sharply reduced.

I really hope the President and Congress take a harder look at their proposals. Perhaps we could save money by allowing them to get health insurance from their spouses or purchasing it in the private market?

Thanks for listening to my rant. I'd love to hear your thoughts.

Tuesday, January 10, 2012

Medicare's Mental Health Coverage

A number of my clients depend on the expertise of geriatric psychiatrists to appropriately address depression, anxiety, or agitation associated with dementia.  They see their doctors and counselors/social workers in inpatient as well as outpatient settings.  How are these services paid for?  Traditional Medicare, like most health insurance plans, provides mental health benefits (Medicare Advantage plans may provide different coverage). The coverage differs, though, for inpatient and outpatient services.

If a Medicare beneficiary receives inpatient services in a psychiatric hospital (i.e., Peachford Hospital or Ridgeview Institute in the Atlanta area), they have the same deductibles and co-pays as for general hospitals.  The big difference, however, is that Medicare beneficiaries have a 190-day lifetime max for inpatient services in a psychiatry hospital.  Beneficiaries can also seek mental health services at a psychiatric unit within acute care hospitals (i.e., Emory's Wesley Woods or Eastside Heritage).  Here is the list of deductibles and co-pays for hospital coverage:

Hospital deductible: $1,156 (waived if the beneficiary is admitted to a psychiatric hospital within 60 days of being discharged from a different hospital) 
Hospital co-pay for days 61-90: $289/day
Hospital co-pay for days 90-150: $578/day

As for outpatient coverage, Medicare will pay 80% of the initial visit to a licensed psychiatrist to determine diagnosis; this is similar to the payments made to other doctors.  Currently, however, the visits made to mental health professionals (e.g., general practitioners, nurse practitioners, physician assistants, psychiatrists, clinical psychologists, clinical social workers and/ or clinical nurse specialists) after that initial visit, is covered by Medicare at 60%, leaving the beneficiary (or their Medigap plan) covering the other 40% of the services.  This coverage will change in the coming years; in an attempt to create mental-health parity, Medicare will cover 65% in 2013 and then 80% for 2014 and beyond. 

For more information, visit www.medicare.gov

Monday, January 2, 2012

CNAs: Vital Partners in Caring

Certified Nursing Aides, or CNAs, play vital roles in caring for our elderly and disabled. CNAs, (sometimes called Home Health Aids) provide such services as bathing, dressing, house-keeping, and supervision for those that cannot do those tasks independently.  An estimated 2 million CNAs perform these vital tasks, meeting the daily needs of many Americans.* I can recall numerous times when I felt awed by the work these ladies (89% of CNAs are women) accomplish on a daily basis.  One instance stands out prominently in my mind.  I was at at the bedside of a woman when she took her last breath.  She was living in an assisted living community, and only myself and the CNA were present at her death.  After notifying the nurse and family that the death had occurred, I remember feeling helpless and at a loss as to what to do next.  The CNA didn't, though.  She promptly filled up a small tub with warm, soapy water and began cleansing the deceased woman's body, preparing her for her family to see her.  She washed her whole body, even applied body powder and a new gown, and fixed her hair before her family arrived to say good-bye.  I was amazed by the CNA's swift action and compassion.  I knew that she did not have to do this.  She could have chosen to move on to her next patient, and yet she seemed to not even think twice about what needed to be done.  The family was moved by the peaceful beauty they found when they saw their loved one, and I am forever in awe of the work of CNAs.  

That story is only one of many that I can recall of a CNA going above and beyond for her patients.  I have consistently witnessed CNAs bring patients into their hearts and care for them like family.  It was not unusual to hear of a CNA buying sweets or Cokes for her patients or picking up some fast food for a housebound patient with a craving.  I have known CNAs to go by their patients' houses off the clock just to check in.  These extraordinary efforts are even more amazing when I consider the compensation most CNAs receive. Recently, I stumbled upon PHI PolicyWorks after reading an article in the New York Times.  PHI Policy Works, a non-profit policy group that represents the interest of direct-care workers (CNAs and HHAs) in the US, publishes some interesting statistics on the working condition of CNAs.   The average wage for a CNA ranges from $9-$12/hour. Disappointingly, 28% of CNAs have no health insurance; this is compared to 18% of the total US workforce. The higher uninsured rates among CNAs may be caused by their part-time work status: 48% of CNAs are employed part-time or full-time part of the year.  In the Metro Atlanta area, it seems to be a common and acceptable practice to hire CNAs prn (as needed) and then assign them to 30-40 hours of work a week.  This arrangement gives the employee enough work to get a consistent paycheck and the employer a break from paying for benefits (e.g., health insurance, paid time-off, sick leave, retirement plans, etc.).  It also allows for the employer to not guarantee a certain amount of work or pay.  If the census of a healthcare organization declines, the employer can just assign the prn staff less hours and save money.  That being said, I have no data or stats on this local phenomenon, and I contend that it may be less common than I have experienced.  

Figuring out how to care for our elderly and disabled citizens while keeping it affordable for consumers and profitable for business is no small task.  I am, however, bothered by the apparent inequities in the working conditions of CNAs.  Their work is hard and so necessary, yet their compensation does not reflect this.  Recently, President Obama announced a new rule that will give CNAs working as in-home care workers the same minimum wage and overtime protections afforded to other workers under the Fair Labor Standards Act.  This group of workers has been excluded since 1974.  This new rule is being hotly debated now, and businesses are claiming the potential unintended consequences of higher costs for consumers and job losses for employees make this new rule faulty.  Perhaps it does, but when 46% of CNAs live in households that rely on public benefits, it seems as if there is something faulty with the current system.

Book recommendations:

Barbara Ehrenreich's Nickel and Dimed 
    Barabara Ehrenreich writes about the world of the working poor by going undercover and doing the work they do.  One of her undercover gigs is as a nursing home aide.  This expose reveals the demanding and often undignified world of low-wage work.

Lauren Kessler's Dancing with Rose
    Laruen Kessler also wrote a book after doing some undercover work as an aide at an assisted living community for folks living with dementia.  Her story was supposed to be about the residents/patients, but she revealed just as much about the people caring for them.  I highly recommend this book to anyone that wants to learn more about the world of institutional care.

Click here to learn more about CNA requirements in Georgia.

*PHI Policyworks stated, "In 2008, over 3 million direct-care workers were employed
in the three occupations: Nursing Aides, Orderlies and Attendants (1,470,000);
Home Health Aides (922,000); and Personal Care Aides (817,000)."

Tuesday, December 20, 2011

Nursing Home Searches

A large part of my job includes helping families find a nursing home for their loved ones.  Families often find caring for their loved ones to be too much physically and financially, and they end up looking to the solution of last resort.  Many spouses and children promise their aging loved one that they will never put them in a "home."  Sometimes, though, the reality of caregiving makes that promise impossible to keep. (Why people resort to nursing homes and the lack of viable community options are different topics to be covered later.)

When talking about nursing homes, I usually start the conversation with the basics: there are two ways to get into a nursing home.  The first, and most preferred method, is to be admitted to a nursing home for rehab after a qualifying 3-day hospital stay.  This is what triggers Medicare to pay the bill (for up to 100 days of rehab).  The other way to be admitted to a nursing home is from home or an assisted living community for long-term care.  Long-term care, unlike rehab care, is not paid for by Medicare and must be subsidized by private funds, VA benefits, long-term care insurance, and/or Medicaid. 

At this point my families are usually still with me.  "Okay, well Mom is not in the hospital, so we just need to find a long-term care bed."  And this is where the conversation gets difficult.  Finding a long-term care bed is difficult.  And it is difficult because of money.  Nursing homes receive two types of revenue: room and board payment for long-term care residents and rehab payments for short-term rehab residents.  The difference between these two revenue streams is not small; the results of a 2009 national survey showed that the average reimbursement per resident per day for rehab was $441.44 and only $171.50 for long-term care residents (assuming the payor-source is Medicaid, which it is for 70% of long-term care residents in nursing homes).  Nursing homes have an incentive to favor short-term rehab residents over long-term care residents, and often the motivation is not only profit but organizational viability.  The nursing home industry reports that for each long-term care resident, the nursing home loses an average of $19.55 per resident per day. That's a (-14.0%) shortfall.  So, how do nursing homes stay afloat?  Luckily, the average profit for short-term rehab residents is 18.1%, which helps balance out the long-term care losses.  For the families that are looking for a long-term care bed at a nursing home, this is bad news.

Most families seem to believe that once they make the painful decision to move their loved one to a nursing home, they will find the best facility closest to their home and schedule an appointment for the move.  We can go over tools to do the search, things to look for, questions to ask (see www.ahrq.gov for some great guides); but most families will likely have to settle for less than their ideal nursing home. The very best of the nursing homes are able to attract short-term rehab residents and turn down long-term care residents.  Finding a long-term care bed seems to come down to who is desperate enough to take the long-term care payment over $0 for an empty bed.  Furthermore, the decision to take a long-term care resident over an empty bed is made on a daily basis, so there is no planning ahead or scheduling the move.  Families must respond immediately to a bed offer and make the move within 1-2 days.  That part is also hard for families.  Moving into a nursing home is not like moving into an apartment or even an assisted living community.  I'm not sure what else in life it is like.  These issues continue to affect residents after admission, too.  Consider a resident who may be well enough to go home or go to an assisted living facility from a nursing home.  The resident will be taking a risk by giving up their nursing home bed.  If their move is not successful and they need to return to a nursing home, will they be able to get back in that nursing home? Will they be able to find any nursing home that will offer them a bed?  These questions must be taken into account when considering leaving a nursing home.

The decision to move a loved one to a nursing home is often painful for families.  Like adding salt to a wound, the nursing homes families get to chose from are often not their first choices, and families have to make painful compromises on either location or quality.  I feel for families facing this situation, and I do my best to empower them with information to hopefully lessen the sting of reality and to reassure them they are doing the best they can.

Reference: http://www.mcknights.com/medicaid-outlook-bleak-for-providers-in-2012-report-finds/article/219572/

Monday, November 28, 2011

The Healthcare Dance

The relationship between healthcare professionals and their patients (patients including both the actual patient and their healthcare proxies) resembles a dance.  And I have begun to realize that neither party always knows whether to follow or lead.  Recently, a woman receiving short-term rehab at a SNF experienced an acute onset of aphasia; she had no prior history of cognitive impairment .  She was alert and oriented but had nonsensical responses to questions and displayed retarded motor movements. This was a new development that came on suddenly.  The nursing home staff examined the resident and called the doctor; the doctor asked the nurses to keep monitoring the resident and call him back with any changes.  The family said, "Well, this should clear up shortly. The doctor has said to just keep watching her."  After 24 hours and no improvement, I pressed the nurses to take a harder look, emphasizing that this is a big change in this resident.  The nurse said, "Well, if the family insists we can encourage the doctor to send her to the hospital for further evaluations."  Did the doctor and SNF staff not realize how big of a change this was for this resident? Did they project cognitive impairment on her that was so common for other SNF residents? Were they waiting for the family to push for more care?  And was the family waiting for the medical staff to push the alarm that something was wrong?  They appeared to be in a dance and not sure who was leading.  My conversation with the nurse led to a longer assessment of the resident and conversation with the family.  The nurse called the doctor and requested that the resident be sent to the hospital. This woman with the acute onset of aphasia had a a cerebrovascular accident, or a stroke.  She spent five days in the hospital and then returned to the SNF with a new rehab plan for speech therapy and a new blood-thinner.  Maybe diagnosing the stroke will make no difference in this woman's outcome, but it made me realize how ambiguous this dance between healthcare professionals and patients can be.  The patient may be assuming and wanting the professionals to be the lead, but the professionals may be waiting for the patient to be in charge, especially in this age of patient-centered careHealthcare, and more so in geriatric medicine, is a give and take from both sides.  Good clinicians realize that they are only seeing a snapshot of the patient and that this patient has about seven decades of complicated social and medical history that cannot be captured in the snapshot.  Thus, patients must fill in those gaps, and healthcare professionals must be willing to take the time to ask good questions and complete full assessments.  Patients and healthcare proxies often must advocate for this level of attention and not sit idly by as healthcare professionals do their jobs.  

Sunday, November 6, 2011

MAGI and Medicaid: How one may change the other

"The Patient Protection and Affordable Care Act” creates a new eligibility category in Medicaid, which will expand access to health care for millions of low-income Americans. For the first time, Medicaid will extend eligibility to all individuals who have income up to 133 percent of the Federal Poverty Level (FPL).  As part of this, states were going to start using a new calculation for income based on the Internal Revenue Code of 1986.  This income test uses a calculation called Modified Adjusted Gross Income, or MAGI, which allows all Social Security benefits to be left out of the calculation.  So, starting on January 1, 2014, all SSDI recipients as well as SS retirement beneficiaries would be able to apply for Medicaid and would be eligible (from an income perspective) if their MAGI (which excludes SS payments) fell at or below 133% of FPL (or $14,484 for a single person in 2011).  So, let me do the math, if a person makes $2,300 in monthly income, and $1,200 of that is from SS retirement payments, and $1,100 is from pension payments, that person (with an annual income of $27,600) could qualify for Medicaid because only $13,200 is counted as income for Medicaid qualification purposes.  (Now, I'm sure there will still be asset limits that will affect Medicaid eligibility, and most people will not meet those asset limits.)

In response to this new change, US Congressman Diane Black (TN-R) proposed HR 2576 to address MAGI.  Her bill would change the IRS code from 1986 so that MAGI would include all Social Security Benefits.  If her bill is adopted (and it passed the house 262-157 on October 27th), then my person in the example above would not be eligible for Medicaid.  Rep. Black assumes that this use of MAGI was an unintended consequence of the ACA that should be fixed (see her post http://black.house.gov/press-release/black-medicaid-bill-passes-house-bipartisan-vote), but I am not so sure. I have listened to both the supporters and the critics, and I am not sure how I feel about it.  This change may result in the denial 500,000 possible Medicaid recipients.  Would these people be better off with Medicaid? Would we all be better off if they had Medicaid (see http://www.cbo.gov/ftpdocs/124xx/doc12484/hr2576.pdf)?  If those 500,000 end up not receiving Medicaid, does that mean they will not be able to afford any health insurance?  And if they have no health insurance (or have to pay a significant portion of their income to health care), will we all be hit harder with higher premiums and increases in healthcare as their medical bills will likely go unpaid?  I suppose if they all did get Medicaid we'd all be paying higher taxes or higher fees for government services.  The assumption seems to be that these individuals would not be eligible for Medicaid but would be eligible to purchase "affordable" health insurance from the health insurance exchanges. I am not so sure those insurance plans will be "affordable."  In regards to HR 2575, my US Rep, Hank Johnson, voted "nay" on October 27th. The Senate will consider HR 674 (HR 2576 was attached to HR 674, and that is another issue altogether) on Monday, November 7, 2011. I suppose we shall see, and I am still not sure where I stand on this issue.