CMS Moves to Strengthen Nursing Home Safety and Clarity of Consumer Info

Published in RINewsToday on January 23, 2023

To improve transparency of nursing home consumer information, the federal Department of Health and Human Services (HHS) through the Centers for Medicare & Medicaid Services (CMS), will now post Care Compare citations that are under dispute by nursing homes on its website.  CMS will also take steps to protect nursing home residents from being inappropriately diagnosed with schizophrenia which oftentimes leads to improper use of anti-psychotic medications to sedate and chemically restrain residents.

“We have made significant progress in decreasing the inappropriate use of antipsychotic medications in nursing homes, but more needs to be done,” said CMS Administrator Chiquita Brooks-LaSure, announcing the new guidance this week. “People in nursing homes deserve safe, high-quality care, and we are redoubling our oversight efforts to make sure that facilities are not prescribing unnecessary medications,” she says.

CMS’s actions advance President Biden’s goal of reinforcing safeguards against unnecessary medication use and treatments that was outlined in his State of the Union address to create an Action Plan for “Protecting Seniors by Improving Safety and Quality of Care in the Nation’s Nursing Homes.”

Tackling the inappropriate drugging of Nursing Home residents

Beginning this month, CMS will conduct targeted, off-site audits of nursing homes to determine whether facilities are accurately assessing and coding individuals with a schizophrenia diagnosis. Nursing home residents erroneously diagnosed with schizophrenia are at risk of receiving poor care and being prescribed inappropriate anti-psychotic medications. Anti-psychotic medications are especially dangerous to these residents due to their potential devastating side effects, including death.

According to the Washington, DC-based National Consumer Voice for Quality Long-Term Care, in 2008, CMS first introduced a quality measure in its Care Compare rating system that calculates the percentage of long-stay residents (over 100 days) that were receiving anti-psychotic medications. This quality measure was initially introduced to address the practice of some nursing homes of illegally using anti-psychotic medications to sedate residents with dementia or other increased patient care needs, rather than providing appropriate hands-on care interventions.

The measure, excluding residents with certain diagnoses, including schizophrenia, Huntington’s disease, and Tourette’s syndrome, resulted in some nursing homes improperly diagnosing residents with schizophrenia, observed the Consumer Voice, a national organization representing consumers in issues related to long-term care, helping to ensure consumers are empowered to advocate for themselves.      

CMS’s new guidance acknowledges that there has been a steady rise in schizophrenia diagnoses since the quality measure was first introduced, charges the Consumer Voice, noting that it comes on the heels of a report issued by the Office of Inspector General for the U.S. Department of Health and Human Services (OIG) which found that from 2015-2019 there was a 194% increase in the number of residents diagnosed with schizophrenia who did not have that diagnosis prior to admission to the nursing home.

“It is important to note that it is extremely rare for schizophrenia to suddenly occur in older people,” says the Consumer Voice, stating that the onset of schizophrenia generally occurs in someone’s late teens through their twenties.

CMS announced that it will begin to conduct audits of nursing homes with high rates of schizophrenia diagnoses and “examine the facility’s evidence for appropriately documenting, assessing, and coding a diagnosis of schizophrenia.” Facilities that have “inaccuracies” will have their Five-Star Quality Measure Rating adjusted. CMS will downgrade the facility’s Quality Measure ratings to one star, which would drop their Overall Star Rating as well. CMS will monitor each facility’s data to determine whether they have addressed the identified issues. After that, CMS will decide whether any downgrades should be reversed.

While Consumer Voice has expressed significant concern with the accuracy of CMS’s Quality Measure, it supports these actions. The Quality Measure rating often inflates a facility’s overall 5-Star rating on Care Compare. This action will help incentivize compliance and make sure the public is aware of these illegal practices in nursing homes, says the consumer advocacy group.

Increased transparency

Separately, CMS announced it plans to take a new step to increase the transparency of nursing home information provided to consumers by publicly displaying survey citations that facilities are disputing. Currently, when a facility disputes a survey deficiency, that deficiency is not posted to Care Compare until the dispute process is complete. This process usually takes approximately 60 days; however, some cases can take longer. 

Although the number of actual deficiencies under dispute is relatively small, they can include severe instances of non-compliance such as Immediate Jeopardy (IJ) citations. This level of citation occurs when the health and safety of residents could be at risk for serious injury, serious harm, serious impairment, or death. Displaying this information while it is under dispute can help consumers make more informed choices when it comes to evaluating and choosing a facility. This new information will begin appearing on Care Compare on January 25th. While citations will be publicly displayed, they will not be included in the Five-Star Quality Rating calculation until the dispute is complete. 

“We support anything that CMS can reasonably do to improve the health and safety of seniors in long-term care, especially those with cognitive impairment. When it comes to the nursing home industry’s concerns about new CMS rules, we think it’s best to err on the side of transparency. Seniors and their families need as much information as possible to make informed decisions about long-term care,” says a spokesperson for the Washington, DC-based National Committee to Preserve Social Security and Medicare, an advocacy group whose mission is to protect Social Security and Medicare.

Local reaction:  “You cannot un-ring a bell”

RI Health Care Association

“We fully support improving nursing home transparency, safety and quality, and accountability regarding our members’ service to the residents and patients entrusted to their care,” says John E. Gage, President and CEO of Rhode Island’s Health Care Association, representing 64 of the 80 nursing facilities in the state. “Eliminating any inappropriate use of psychotropic medications and ensuring the highest quality of care is a shared focus of both CMS and RIHCA,” notes Gage.

“We strongly disagree with CMS’ decision to post of deficiencies that are in the process of being disputed through established CMS policies, regardless of their scope and severity, says Gage. “Posting deficiencies that, in many instances, are incorrect, inaccurately cited or cited at an inappropriate level of scope and severity, during an approved appeals process is unfair and could damage a facility’s reputation unfairly,” he adds.

According to Gage, doing this is akin to convicting someone before their full trial, (prosecution and defense alike) before the verdict is announced. “You cannot “un-ring a bell,” he says.

“As mentioned by CMS, we are just talking about a relatively small number of deficiencies,” states Gage. Rather than potentially posting erroneous deficiencies, he calls on CMS to speed up the process of conducting Informal Dispute Resolutions (IDRs) or Independent Dispute Resolutions (IIDRs) to no more than forty-five (45) days to ensure that accurate information is posted timely. IDRs and IIDRs are two different options from CMS that nursing homes can choose to appeal of cited deficiencies.

“As to the changes to the public reporting and the Five-Star Quality Rating System, we are disappointed that the Biden Administration and CMS have apparently made this determination administratively, without any comment period to allow for an opportunity for nursing homes and the public to provide feedback,” says Gage.

LeadingAge RI

“I appreciate CMS’s goal of increasing oversight of unnecessary antipsychotic medication use, although it should be noted that there has been a National Partnership to reduce the unnecessary use of antipsychotic drugs for years, so the industry has been very engaged in these efforts already,” notes James Nyberg, Executive Director of LeadingAge RI, a not-for-profit membership organization comprised of not-for-profit providers of aging services. 

Nyberg expresses concern about CMS posting deficiencies that are under dispute publicly. “That is taking a guilty before proven innocent approach, which is unfair and detrimental to providers. There is an existing process to resolve disputes over deficiencies, and this seems to short-circuit it, especially when deficiencies can be/and are overturned during the process.  One more blow to a beleaguered industry,” he says.

Long-Term Care Ombudsman

“The inappropriate use of antipsychotic medications in nursing homes has been an on ongoing issue for many years,” observes Kathleen Heren, Rhode Island’s Long-Term Care Ombudsman. “It takes a skilled practitioner who gives a battery of tests to diagnose someone with schizophrenia. This shouldn’t be determined by a hospital intern who spends 20 minutes with an agitated resident in a hospital emergency room,” she says.

According to Heren, schizophrenia has an early onset [about 4% of schizophrenia arise before the age of 15, and about 1% before the age of 10].  A 78-year -old resident does not become schizophrenic all of a sudden because he or she is agitated. “I can say that I have not seen many deficiencies given to Rhode Island nursing homes for overusing anti-psychotic medications,” she says, because of the efforts of  Health Care Centrics, Rhode Island’s Quality Assurance organization, that has provided in-depth staff training on the use of these drugs. The surveyors from the Rhode Island Department of Health (RIDoH) are very quick to cite facilities for not following guidelines in the inappropriate use of these drugs.

Heren says that there have been cases where RIDOH has rescinded a deficiency based on the input received by the survey team during the Informal Dispute Resolution process. “There are some facilities that are continually receiving deficiencies and that families should be able to see why a deficiency was given and a facilities response as to why it was considered unfair,” she says.

CMS Actions promote quality of care

RI Department of Health

“At the Rhode Island Department of Health (RIDoH), one of our major focus areas is monitoring and ensuring that nursing homes and other healthcare facilities provide the highest quality of care and services in a clean and safe environment, says Joseph Wendelken, RIDoH’s Public Information Officer. 

“We will continue to do everything we can to protect patients and residents, which includes following any new CMS protocols and partnering with CMS on new initiatives,” Wendelken says. 

Senior Agenda Coalition of RI

Adds Maureen Maigret, Policy Advisor for the Senior Agenda Coalition of RI, “Rhode Island nursing homes have generally provided good quality of care over the years,” acknowledging that improvements can always be made. “Both of these changes are intended to promote better quality care,” she says. “If people are erroneously coded as having schizophrenia, they may be subject to poorer care and harmed by being prescribed inappropriate medication. Posting inspection citations under dispute on Nursing Home Compare with a notation they are under dispute is important in that resolution of the dispute could take 60 days or longer and in the meantime the public remains unaware of what could be significant deficiencies which could impact their decisions,” states Maigret says.

The QSO memo — Updates to the Nursing Home Care Compare website and Five-Star Quality Rating System: Adjusting Quality Measure Ratings Based on Erroneous Schizophrenia Coding, and Posting Citations Under Dispute — is available here for review:

https://www.cms.gov/medicare/provider-enrollment-and-certification/surveycertificationgeninfo/policy-and-memos-states/updates-nursing-home-care-compare-website-and-five-star-quality-rating-system-adjusting-quality

Trustee Reports predict improved outlook for Social Security and Medicare

Published in RINewsToday on June 6, 2022

On June 2, 2022, following a meeting of the Social Security and Medicare Boards of Trustees, the Social Security Administration (SSA) – joined by the Departments of Health and Human Services and Labor, the Centers for Medicare & Medicaid Services, and the U.S. Department of Treasury — released a 275-page annual report giving us a snapshot of the financial health of the Social Security Trust Funds.

The Trustee reports findings

According to this year’s Trustee Reports, “Social Security and Medicare both face long-term financing shortfalls under currently scheduled benefits and financing. Costs of both programs will grow faster than gross domestic product (GDP) through the mid-2030s primarily due to the rapid aging of the U.S. population. Medicare costs will continue to grow faster than GDP through the late 2070s due to projected increases in the volume and intensity of services provided.”

The Social Security Trustees report that the combined asset reserves of the Old-Age and Survivors Insurance and Disability Insurance (OASI and DI) Trust Funds, paying benefits to 65 million retirees, disabled people as well as survivors of deceased workers, are projected to become depleted in 2035, one year later than projected last year, with 80 percent of benefits payable at that time. The DI Trust Fund asset reserves are not projected to become depleted during the 75-year projection period.

“It is important to strengthen Social Security for future generations. The Trustees recommend that lawmakers address the projected trust fund shortfalls in a timely way to phase in necessary changes gradually,” says Kilolo Kijakazi, Acting Commissioner of Social Security in a statement announcing the released report. “Social Security will continue to be a vital part of the lives of 66 million beneficiaries and 182 million workers and their families during 2022,” she adds.   

The Medicare Board of Trustees note in its 263 page report that the projected depletion date for Medicare’s trust fund for inpatient hospital care (Part A), covering around 64 million retirees and disabled persons, moved from last year’s forecast of 2026 to 2028. At this time Medicare will only be able to pay 90% of the scheduled benefits when the fund is depleted.

“We are committed to running a sustainable Medicare program that provides high quality, person-centered care to older Americans and people with disabilities,” said CMS Administrator Chiquita Brooks-LaSure. In a statement “Medicare trust fund solvency is an incredibly important, longstanding issue and we are committed to working with Congress to continue building a vibrant, equitable, and sustainable Medicare program,” she says.

Thoughts from senior advocacy groups

In a statement, AARP CEO Jo Ann Jenkins said that this year’s Social Security and Medicare Trustee report sends this clear message to Congress: “The Social Security and Medicare Trustees’ reports should send this “clear message” to Congress: “Despite the short-term improvement, you must act to protect the benefits people have earned and paid into both now and for the long-term. The stakes are too high for the millions of Americans who rely on Medicare and Social Security for their health and financial well-being.”

“These reports also underscore the urgent need for Congress to pass legislation allowing Medicare to negotiate for lower prescription drug prices, which would result in billions of dollars of savings for seniors, the Medicare program, and taxpayers,” says Jenkins.

Jenkins also calls on Congress to increase funding to fix serious long-time Social Security customer service problems, which currently impede or keep seniors and people with disabilities from getting their benefits in a timely manner.

Following the release of the Trustees Report, Executive Director Alex Lawson, of the Washington, DC-based Social Security Works, (SSW) a social welfare organization that lobbies for Social Security Reforms, also issued a statement: “Today’s report shows that our Social Security system remains strong. Protecting and expanding benefits is a question of values, not affordability. That this year’s projections are even stronger than last year’s proves once again that Social Security is built to withstand times of crisis, including pandemics.”

We don’t have a Social Security crisis, but we do have a retirement income crisis. With prices rising, seniors and people with disabilities are struggling to afford food and medicine. The solution is to expand Social Security,” says Lawson. 

According to SSW, the 2020 Social Security Trustee’s Report reported that Social Security has an accumulated surplus of about $2.85 trillion.  It projects that, even if Congress took no action whatsoever, Social Security not only can pay all benefits and associated administrative costs until 2035, it is 90 percent funded for the next quarter century, 84 percent for the next half century, and 81 percent for the next three quarters of a century.  

“At the end of the century, in 2095, Social Security is projected to cost just 5.86 percent of the gross domestic product (“GDP”), less than most other wealthy countries spend on their counterpart programs,” says SSW.

Max Richtman, President and CEO of the Washington, DC-based National Committee to Preserve Social Security and Medicare (NCPSSM), throws in his two cents about this year’s Trustee Report. “The takeaway from the latest Social Security Trustees report is this:  Congress must strengthen the program’s finances without delay. The Trustees project that the combined Social Security retirement and disability trust fund will become depleted by 2035, one year later than projected in their previous report. At that point, every Social Security beneficiary will suffer a 20% cut to their benefits.”

“Seniors struggling to meet rising living expenses need Social Security to be boosted and strengthened. The pandemic, runaway inflation and devastating stock market losses serve to remind us how vital a robust Social Security program is to workers, retirees, the disabled and their families. The clock is running down. The time for fair, just, and equitable action that safeguards Social Security’s financial stability is now,” adds Richtman.   

While acknowledging that the trust fund insolvency date may fluctuate from year to year, the urgent need to boost the program’s financing and benefits remains consistent, says Richtman. 

NCPSSM’s Richtman says, over the years, the GOP has opposed the expansion and strengthening of Social Security and has called for raising the retirement age, privatization, and more recently, ‘sunsetting’ Social Security and Medicare every five years.  He calls for passage of Rep. John Larson’s Social Security 2100: A Sacred Trust legislation that would extend trust fund solvency by requiring high wage earners to contribute their fair share through an adjustment in the payroll wage cap. 

A Washington Insider says that House Speaker’s Nancy Pelosi (D-CA) policy staff are concerned about the cost of Larson’s Social Security fix legislation and are seeking a CBO cost estimate. At press time this measure has more than 200 Democratic cosponsors in the House. The Congressional Asian Pacific American Caucus (CAPAC), Congressional Black Caucus (CBC), the Congressional Hispanic Caucus (CHC), the Task Force on Aging and Families, and the Congressional Progressive Caucus have all called on Pelosi to bring the bill to the House floor for a vote.

“Thanks to the American Rescue Plan, our economic recovery has strengthened both the Social Security and Medicare Hospital Insurance Trust Funds and improved financial projections for these vital programs. But to ensure that every American worker, senior, child, and person with disabilities receives the necessary and earned benefits provided by both Social Security and Medicare, we need to act. That’s why I am an original cosponsor of legislation like Social Security 2100: A Sacred Trust, to not only enhance benefits for seniors and some of our most vulnerable neighbors, but to also guarantee access to these programs for generations to come,” said Congressman David Cicilline, (D-RI).  

Congress can step in to financially strengthen the Social Security and Medicare programs. A message from the Social Security and Medicare Boards of Trustees suggest Congress pass legislation to reduce or eliminate the long-term financing shortfalls in both the Social Security and Medicare. “Taking action sooner rather than later will allow consideration of a broader range of solutions and provide more time to phase in changes so that the public has adequate time to prepare,” say the Trustees.

Congress should look for “medium-term solvency” fixes to ensure that Social Security program can pay full benefits for several decades rather than for the full 75-year projection period, suggests Paul N. Van De Water, Senior Fellow at the Washington, DC-based Center for Budget and Policy Priorities, a nonprofit nonpartisan research organization and policy institute that conducts research on government policies and programs. “But shoring up the program’s financing for a substantial period of time is important for assuring both current and future beneficiaries that Social Security will be there for them in the years to come,” he says.

At a crossroad

NCPSSM’s Richtman believes Social Security’s future is now at a crossroads. “We can either cut benefits or expand benefits and pay for it by requiring the wealthiest to pay their fair share,” he says, calling on Congress to hold an up or down votes on Larson’s Social Security legislation.

Polling shows that voters support fixing Social Security and Medicare. Seniors may well go to the polls, sending a message with their vote that strengthening and expanding Social Security is important to them.   

For a copy of the 2022 Social Security Trustee Report, go to https://www.ssa.gov/OACT/TR/2022/tr2022.pdf. For a copy of the 2022 Medicare Trustee Report, go to https://www.cms.gov/files/document/2022-medicare-trustees-report.pdf

Medicare slow to fix equity issue for seniors’ access to at-home COVID test kits

Published on Feb. 7 in Rhode Island News Today

Today home test kits were made available in a variety of ways – but, for Medicare recipients, it was a different story, being forced to go thru a different purchasing and payment process than those having private insurance, or no insurance. That process required the oldest and most at-risk population to take more than several steps, put up their own money, do a lot of paperwork, to seek reimbursement.

The White House made changes in testing so that at-home tests are now fully covered by health insurances. Those insured can pick up their test kits in a store and have them paid for at the time of purchase by their insurance, at no cost to the person. They aren’t required to visit their physician or get a prescription to obtain the free test. They have a limit of 8 test kits per month.

But, when the program began, this was not the plan for those insured through the government’s Medicare and Medicare Advantage plans.

Red Tape… Upfront Charges for COVID-1

Jane, a 65-year old Medicare beneficiary from Warwick went through the steps to get a kit after a relative she had seen found out she was exposed to COVID.  Before Medicare announced easing up on the purchasing process of COVID-19 test kits, she expressed frustrations to this writer about the regulatory hoops she faced because she was on Medicare – purchasing the test kits and getting reimbursed for the upfront charges. “First, I had to request a prescription from my physician and say that I had either been exposed to someone who had COVID, or I was having symptoms, myself,” recalls the frustrated Medicare beneficiary.  “Once my physician sent the prescription over to CVS, I was notified that it would take a couple of days before I could pick up the kits and that I would only be given two kits per prescription”, she fumed, knowing that sometimes it takes 4 or 5 days of testing to test positive, but was only eligible to receive two, and she might have to go through the whole process again in a few days.

“Three days later CVS finally left me a message saying these kits were in. I used the drive-up window for pickup and the cashier asked me for $46,” Jane remembered.  “When questioning this charge, a pharmacist came to the window to assist and told me that I had to pay for the kits upfront and then seek reimbursement,” she added.

Paying for the kits, Jane went home, and called Blue Cross, her Medicare supplement company and was told she needed to request a copy of the prescription which took hours to finally request with the back and forth phone calls to her busy doctor’s office. It was almost two weeks later she finally got a copy of the receipt detailing her $46 payment for the kits. She was then able to upload the copy of the prescription and a copy of her receipt to a BCBS reimbursement screen on her computer (or she could have printed the form out and mailed the whole package in). At press time, Jane is still waiting for her reimbursement, being told it will take from 4 to 6 weeks to receive a check.

It’s better late than never, says Jane, when she heard that Medicare would now cover free over-the-counter COVID-19 tests. “Not everyone can put out $46 and wait two months to get it back, home health tests were made available in a variety of ways – but, for Medicare recipients, there was a different process. More concerning was all the steps I had to take to complete the process they had originally intended for us to do. How many people would really complete all those steps?” she says. “We talk a lot about equity, but seniors need equitable healthcare processes, too.”

Just days ago, the Centers for Medicare & Medicaid Services (CMS) announced that beneficiaries in either Original Medicare or Medicare Advantage will be able to get over-the-counter COVID-19 tests at no cost starting in early spring, estimated to be in April. Under the new CMS initiative, Medicare beneficiaries will be able to access up to eight over-the-counter COVID-19 tests per month for free. Tests will be available through eligible pharmacies and other participating entities. This policy will apply to COVID-19 over-the-counter tests approved or authorized by the U.S. Food and Drug Administration (FDA). A prescription will not be required.

CMS Unveils New Medicare Benefit

According to CMS, this new initiative will enable payment from Medicare directly to participating pharmacies and other participating entities to allow Medicare beneficiaries to pick up tests at no cost. This is the first time that Medicare has covered an over-the-counter test at no cost to beneficiaries.

CMS’s announcement follows last month’s announcement that the Biden-Harris Administration would be requiring commercial health insurance companies to cover at-home COVID tests for free.

Until the new benefit kicks in, Medicare beneficiaries can access free tests through a number of channels established by CMS, too. Now, they can request four free over-the-counter tests for home delivery at covidtests.gov. Or beneficiaries can access COVID-19 tests through health care providers at over 20,000 free testing sites nationwide. Many cities and towns are also giving out free test kits at drive-up handout programs as the state receives supplies.

CMS’s Feb. 3 statement noted that Medicare beneficiaries can also access lab-based PCR tests and antigen tests performed by a laboratory when the test is ordered by a physician, non-physician practitioner, pharmacist, or other authorized health care professional at no cost. In addition to accessing a COVID-19 lab test ordered by a health care professional, people with Medicare can also already access one lab-performed test without an order, also without cost sharing, during the public health emergency, says CMS.

In addition, CMS says that Medicare Advantage plans may offer coverage and payment for over-the-counter COVID-19 tests as a supplemental benefit in addition to covering Medicare Part A and Part B benefits. Medicare beneficiaries covered by Medicare Advantage should check with their plan to see if it includes such a benefit.

Finally, all Medicare beneficiaries with Part B are eligible for the new benefit, whether enrolled in a Medicare Advantage plan or not.

“AARP applauds today’s announcement that will guarantee access to at-home over-the-counter COVID-19 tests at no cost for Medicare’s 64 million beneficiaries and we thank [Health and Human Resources]Secretary Becerra and CMS Administrator Brooks-LaSure for their diligence in addressing this issue. Expanded access to no-cost testing will help protect seniors who have been hit hardest by the pandemic and ensure they can remain connected with their loved ones and community.,” says AARP Executive vice president and Chief Advocacy and Engagement Officer Nancy LeaMond in a statement issued with CMS’s Feb. 3rd announcement of the new Medicare benefit.

“Every American should have an easy way to get at-home COVID tests. We know that people 65 and older are at much greater risk of serious illness and death from this disease – they need equal access to tools that can help keep them safe. The cost of paying for tests and the time needed to find free testing options are barriers that could discourage Medicare beneficiaries from getting tested, leading to greater social isolation and continued spread of the virus, adds LeaMond.

Successfully Advocating the Seniors

Last month, Senators Sherrod Brown (D-OH) and Debbie Stabenow (D-MI) along with 17 of their  Senate colleagues including Rhode Island Democratic Senators Reed and Sheldon Whitehouse wrote to HHS Secretary Becerra and  CMS Administrator Brooks-LaSure urging them to expand Medicare coverage of free at-home rapid COVID-19 testing.

Aging groups also joined the Senators in pushing Medicare to offer the new testing kick benefit.  “It is clear that regular testing is a crucial part of managing the spread of COVID-19. That’s why AARP has been calling for coverage of at-home tests, says AARP’s LeaMond, noting that the nation’s largest aging advocacy group “will continue to watch for details about when and how at-home COVID tests are made available to those in Medicare.”

Thankfully CMS quickly heeded their calls.

For more information, please see these Frequently Asked Questions, https://www.cms.gov/files/document/covid-19-over-counter-otc-tests-medicare-frequently-asked-questions.pdf (PDF)

Stay tuned for free N95 masks to be made available to all coming up soon.