Tag Archives for Centers for Medicare & Medicaid Services

Regulatory approval can make a belated Christmas miracle happen

Published in RINewsToday on April 8, 2024

A belated Christmas miracle may truly happen, if state and federal agencies allow the Linn Health & Rehabilitation to convert one of its floors into affordable assisted living specializing in memory and dementia care. If this happens, says the facility’s management and its Board of Trustees it will keep the East Providence-based nonprofit facility from closing, preventing the displacement of residents and staff. 

Faced with rampant inflation, rising food and utility costs, high temporary staffing agency fees, and very low state Medicaid reimbursement rates that haven’t kept pace with increasing costs in over a decade, Linn Health, established over 52 years ago, publicized its financial troubles over four months ago.   

The Best of the Best 

When the news broke about Linn Health & Rehabilitation’s financial crisis over four months ago, the facility had just been named a 2024 ‘Best Nursing Home’ and ‘High-Performing’ short-term rehabilitation home in the nation by U.S. News & World Report, states Jamie L. Sanford, LNHA, LCSW, administrator of Linn Health & Rehabilitation.

“Here we are, one of the elite nursing homes in the United States, and we are finding it difficult to stay afloat like six other homes in our local market who have gone out of business, and three others who have declared bankruptcy, and one other who recently had to downsize by 50 beds,” says Sanford.

“It’s sad that Rhode Island families who deserve an affordable 5-star nursing home like ours don’t have the option because of inadequate Medicaid reimbursement. The struggle is real,” says Sanford.

Together with Aldersbridge Communities and its volunteer Board of Trustees, Linn leaders launched a savvy PR move, calling it a “Hail Mary” effort, to find its Christmas miracle donors and funding to prevent it from closing or forcing the displacement of 71 residents and the laying off of 150 staff members. A clever twist on the message resulted in a story on Rhode Island television stations, talk radio, and pick up by other media outlets.

“Our tireless pleas for funds to keep us afloat until a slight Medicaid reimbursement rate increase is expected to take place later this year were heard, but didn’t result in us receiving any emergency gap funding. We did receive charitable contributions from generous donors in earnest, but the amount was nowhere near enough to cover our losses of $100,000 per month,” states Richard Gamache, MS, FACHCA, chief executive officer of Aldersbridge Communities. With revenues dwindling, Linn leadership came up with a solution: convert one floor of the nursing home into affordable assisted living, specializing in memory and dementia care”, he notes. 

Submitting the Application

According to Gamache, its application for recertification was submitted last month and he expects the license to be approved by the RI Department of Health soon. “Obtaining our certification so that we can bill the Centers for Medicare & Medicaid Services is a bigger obstacle, because the federal government is involved,” he says. But, it could take “one or two months to get the facility’s licensing and certification approved by the RI Department of Health and Human Services (RIDHS) and CMS.  

If approved and certified, Linn Health & Rehabilitation will operate “The Loft at Linn” – a new assisted living memory care unit featuring 22 private studio apartments on the second floor of the building. The third floor will remain a licensed nursing home, albeit smaller now with 33 beds.

According to Gamache, the RIDHS has recertified Linn residents currently receiving long-term care to qualify for assisted living-level memory care, enabling them to continue to live at Linn and have the same caregivers they are used to and know. 

Meanwhile, grant funding from the Rhode Island Foundation, the Ruby Linn Foundation, and other sources are being used to pay for the apartment renovations; and to re-educate and train certified nursing assistants to become certified medical technicians so they can remain on staff working at the assisted living memory care program.

Shifting operations to assisted living and repurposing existing nursing home rooms will keep the facility’s doors open. “It’s not enough to solve our financial woes completely, as we expect the nursing home to continue to lose money – just not as much as we have been losing,” notes Gamache. “The irony is that we will save Rhode Island over $780,000 in a year because of the difference between what they will reimburse us for assisted living, versus a skilled level of care per Medicaid resident,” Gamache calculates. 

As a whole, because we’re going from a 42-bed skilled nursing floor to a 22-bed assisted living floor, the state is going to save $2.8 million per year in Medicaid dollars,” notes Gamache.

It is not surprising that Rick Gamache, who has years of experience managing nursing facilities, might have just found a way to keep his facility open,” says Kathleen Heren, Rhode Island’s Ombudsman. If the request of recertification is approved by state and federal regulators to offer assisted living with memory care, residents won’t be displaced and workers won’t lose their jobs, says Heren.

“It was never a viable option to sell Linn Health to an out-of-state nursing facility chain,” says Heren, noting that there is a need for assisted living facilities offering memory care. “There are high functioning people affected with dementia, with no medical conditions, who do not need to be placed in a nursing facility,” she adds.

Comments from the Sideline 

Like Heren, Maureen Maigret, policy advisor for the Senior Agenda Coalition and member of the RI Advisory Council on Alzheimer’s Disease Research and Treatment, holds Gamache in high regard. By converting a floor to needed assisted living with a memory care, staff will not be displaced, so residents with memory issues will not be losing staff who know them and who they are comfortable with.

According to Maigret, many assisted living residences strictly limit residents on Medicaid. A few years back, the state changed the Medicaid reimbursement for assisted living to one with three levels of reimbursement with a higher level of reimbursement to encourage more residences to accept persons with higher needs who are on Medicaid. ”We know that RI has many persons with diagnoses of Alzheimer’s and related dementias so such memory care programs are critical for those who cannot pay privately with monthly rates often over $6,000,” says Maigret.

Maigret notes that the state’s Health Department reports that 34 assisted living residences are licensed as Special Care/Alzheimer’s residences, but it is does not show which ones accept Medicaid. “And even those that do often limit the number of residents on Medicaid as they can get higher reimbursements from private paying persons,” she says.

According to Gage, in 2024, RI’s nursing homes are being paid rates by Medicaid that are based on their 2011 actual costs under the price-based reimbursement system that was implemented in 2013. Core principles of this reimbursement methodology are the statutory annual inflation adjustments and a Medicaid rate analysis every three years to determine whether rates are reasonable and adequate. “In the vast majority of years in the past decade, RI Medicaid has slashed or eliminated inflation adjustments, and they have never conducted a rate analysis/adjustment.  As a direct result, RI nursing homes are losing $50-75/day on each resident receiving care under Medicaid,” he says.

Gage predicts that Linn and Scandinavian Home will not be the last to make the difficult choice to downsize or close. “Just since the start of the pandemic, six RI nursing homes have closed and three were in receivership. Now, two nonprofit homes are forced to downsize their facilities,” he noted. “RI nursing homes must be adequately reimbursed by Medicaid under a stable and sustainable reimbursement system, and there needs to be bold action to recruit and retain frontline healthcare workers at competitive rates,” he warns, calling for the state to preserve nursing facilities. 

Demographics show a silver tsunami on the horizon. We need to ensure that there will be capacity for those who will need short-term or long-term care and services in the coming years,” states Gage.

As far as any potential Medicaid savings resulting from the planned conversion, Gage says that Linn would only be able to accommodate 33 nursing facility residents down from its former capacity of 87. By downsizing the nursing home by 54 beds and transitioning that floor into low-income memory care assisted living for just 22 residents, there will be a savings to the state, he says. due to the combined capacity of the facility decreasing by 32 residents, and those who remain in the memory care unit will be receiving a lower level of care and assistance than that provided in a skilled nursing home.

At press time, Gamache waits for the license from RIDOH and certification from the Centers for Medicare & Medicaid Services to be approved that enables the opening of the new assisted living memory care program. 

“There is no reason while this approval shouldn’t happen,” says Gamache. “We can comply with all the regulations, we’ve identified an overwhelming community need, and we are saving the state a lot of money,” he quipped. 

“After all, this is a win/win for the state, for residents, their families and staff to enable Aldersbridge Communities continue operating a full continuum of care,” states Gamache. 

Federal Court denies attempt to stop Medicare drug negotiation program

Published in RINewsToday on November 6, 2023

Over two months ago, as supporters of President Biden’s Inflation Reduction Act (IRA) celebrated the one-year anniversary of the passage of the historic legislation, the U.S. Chamber of Commerce, Pharmaceutical Research and Manufacturers of America (PhRMA), along with drugmakers filed multiple lawsuits to block the IRA’s drug price negotiation provisions.  The drug price negotiation program, created by IRA, allows Medicare to use its bargaining power to negotiate the prices of ten prescription drugs for the first time.

The multiple-filed legal suits came weeks before Sept. 1 when the for Centers Medicare & Medicaid Services (CMS) was scheduled to publish a list of the first 10 drugs that would be subjected to negotiations.  These lawsuits argued that the federal price negotiation program was unconstitutional because it violated the First and Fifth Amendments of the U.S. Constitution, as well as the separation of powers clause, by giving the U.S. Department of Health and Human Services (HHS) discretion over a maximum fair price for any given drug selected for negotiation.  These lawsuits also charge that CMS price controls would force drug makers to pull back on developing new drugs, jeopardizing medical breakthroughs for individuals with life-threatening and chronic illnesses. 

Among the nine lawsuits scheduled to go to trial, one was a motion filed on July 12, 2023 by the Chamber and several of its affiliates in Ohio. This motion requested the court to issue a preliminary injunction to halt the Medicare drug negotiation program from implementation. The ruling came before the Oct. 1, 2023 deadline requiring drugmakers whose pharmaceuticals were selected for negotiations to either sign agreements to participate or to face stiff penalties.  

The U.S. Department of Justice opposed the Chamber’s motion, filing a motion to dismiss its case.  On Sept. 15, 2023, the court held oral arguments giving the  Chamber and the DOJ an opportunity to present their legal arguments in greater detail.  

Overcoming a Major Legal Hurdle 

On Friday, September 29, 2023, U.S. District Judge Michael J. Newman for Southern District of Ohio, denied the Chambers request to block implementation of the newly established Medicare drug price negotiation program before the drug price negotiation talks began.  The ruling called on the Chamber to file an amended complaint by Oct. 13, 2023. DOJ would then have until Oct. 27, 2023 to renew its motion to dismiss.

According to Spencer Kimball of CNBC, legal experts say the pharmaceutical industry hopes to see conflicting rules from lawsuits filed in other federal appellate courts to bring this issue to the Supreme Court for final resolution. 

The Willimantic, Connecticut-based Center for Medicare Advocacy (CMA), a nonprofit group pushing for comprehensive Medicare coverage, health equity and quality of health care for seniors and people with disabilities, is encouraged by Judge Newman’s ruling, which assessed the drug manufacturer’s claims “to be weak in the face of clearly established laws.”

According to CMA, the 28-page court order found that the Chamber and other plaintiffs had demonstrated neither likelihood of success on the merits, nor irreparable harm, which are required for a preliminary injunction.  CMS noted that this case cited “clear” law that “participation in Medicare, no matter how vital it may be to a business model, is a completely voluntary choice.” The court also found that the price established by negotiations cannot be considered ‘confiscatory,’ as the Chamber charges or “a violation of due process, because drug manufacturers can opt out of Medicare entirely.”

Newman’s ruling noted that drugmakers are not compelled to sell drugs at the prices established by the Medicare program and that any economic harm, when the negotiated drug prices take effect in 2026, was too speculative to warrant immediate relief, reported CMS.  However, the court did deny the government’s motion to dismiss the lawsuit entirely, saying that more information on whether the plaintiffs have standing to sue would be beneficial and therefore the judge is allowing for limited discovery to clarify issues related to legal standing, after which the government may renew its motion to dismiss, noted the Medicare advocacy group.

With this ruling, Medicare may move forward with its implementation of its drug negotiation program as this case and others continue to proceed. 

Giving their two cents…

At press time, the Chamber did not respond to a request for comment about the court’s ruling.  But health care and aging advocacy groups issued statements expressing their thoughts about the impact of Newman’s ruling. 

“This is the first major blow to Big Pharma in its legal battles to block the drug price negotiation provisions under the Inflation Reduction Act, says Peter Maybarduk, Public Citizen’s director of the Access to Medicines program.

“The Chamber’s lawsuit lacks merit; the court made the right decision not to grant the injunction, which would have caused needless patient suffering and treatment rationing, notes Maybarduk, calling on drugmakers “to drop their lawsuits and drop their prices.”

“Now, drug companies should agree to participate in the negotiation program in good faith. The program is an important first step in ending the exorbitant prices charged to Medicare enrollees,” adds Maybarduk.

Frederick Isasi, Executive Director of Families USA, happily noted that the Medicare drug negotiation program continues, calling the ruling “a big win for seniors and their ability to purchase life-saving medications. The ability to afford medication is a matter of life and death for millions of older adults. That’s why we are fighting this David and Goliath battle – people deserve to pay a fair price for their drugs and Medicare price negotiation is a critical piece of this puzzle. And let’s not forget each drug subject to fair price negotiation is an old drug that millions of people need and doesn’t have competition,” he notes.

“It never ceases to amaze us that – on one hand – Big Pharma can cry poverty by saying that drug negotiations will hurt their bottom line, while recent earnings reports show they are raking in money hand over fist.  We are glad Judge Michael J. Newman, a Trump appointee in Ohio’s Southern District, saw through this hypocrisy by affirming the Biden administration’s power to begin negotiating the prices of 10 medications with drugmakers,” says Dan Adcock, Director of Government Relations and Policy, of the Washington, DC-based National Committee to Preserve Social Security and Medicare. (NCPSSM).

According to NCPSSM, Drug makers made a whopping $493 billion in revenue from ten drugs that are now subject to price negotiations between CMS and the manufacturer, which have accounted for more than $170 billion in gross Medicare spending, according to a report from the nonprofit, Protect Our Care.

“The court’s decision to allow Medicare drug price negotiations to move forward is welcome news, says William Alvarado Rivera, Senior Vice President for Litigation at AARP Foundation. “Pausing Medicare negotiations would have risked billions of dollars in savings for taxpayers – and countless lives. It is unconscionable that Americans face such high prescription drug costs that many people skip taking medication altogether or must ration it,” he said.

“We’re prepared to fight for as long as necessary to ensure big drug companies can’t charge excessive prices at the expense of patients’ health, says Rivera, noting that the new Medicare negotiation law would bring financial and medical relief to millions of older Americans and their families, and put drugs that treat life-threatening and chronic conditions, from cancer to heart disease, within their reach. Rivera says, “It must not be derailed.” 

Congress has put the breaks to the spiraling costs of pharmaceuticals by giving Medicare the authority to negotiate the price of popular drugs with drug makers.  America’s seniors will continue to suffer financial  hardships and many might even lose their lives by not choosing not to take their costly medications if courts rule in favor of drug companies.  Time will tell.   

U.S. Judge Michael J. Newman ruling denying the U.S. Chamber of Commerce’s request for a preliminary injunction, go to https://www.bloomberglaw.com/public/desktop/document/DaytonAreaChamberofCommerceetalvBecerraetalDocketNo323cv00156SDOh/5?doc_id=X3U600KOGG69QHQBPEU24OS1JMO

A listing of drugmaker revenues of the first ten negotiated drugs, go to https://www.protectourcare.org/by-the-numbers-the-ten-costly-drugs-that-are-now-eligible-to-have-lower-prices-negotiated-by-medicare/

Senate bipartisan proposal boon to nation’s family caregivers

Published on October 30, 2023

Many family caregivers will tell you that coping with the stress of providing care to loved ones, is made more difficult when they are forced to navigate the confusing federal bureaucracy to identify key financial and health care programs for support. Last week, S 3109, the Alleviating Barriers for Caregivers (ABC) Act, was thrown into the legislative hopper to make it easier for more than 48 million family caregivers to obtain this information. The Senate caregiver proposal was referred to the Senate Finance Committee and no House companion measure has been introduced at press time. 

On Oct. 24, the bipartisan Senate proposal was introduced by Senators Edward Markey (D-MA) and Shelley Moore Capito (R-WV) and is co-sponsored by Senators Kyrsten Sinema, (I-AZ), Susan Collins (R-ME), Bob Casey (D-PA), and Thom Tillis (R-NC). The proposal would require the Administrator of the Centers for Medicare & Medicaid Services and the Commissioner of Social Security to review and simplify the processes, procedures, forms, and communications for family caregivers to assist individuals in establishing eligibility for, enrolling in, and maintaining and utilizing coverage and benefits under the Medicare, Medicaid, CHIP, and Social Security programs respectively, and for other purposes. The agencies must conduct a review and seek input from family caregivers prior to taking actions that would improve their experiences coordinating care for their loved ones.

Currently, more than 48 million family caregivers in the U.S. help take care of loved ones. According to AARP and the National Alliance for Caregiving in the U.S. report, caregivers provide support ranging from selecting the best providers; coordinating multiple health and long-term care providers; navigating the care system; advocating with providers, community services, and government agencies; and managing medications, complex medical tasks, meals, finances, and more.

According to AARP, most caregivers say additional information and support for managing these needs is essential. One in four family caregivers (25%) report they want help figuring out forms, paperwork, and eligibility for services and 26% say that it is difficult to coordinate care across various providers and services. While most (61%) work full- or part-time, and some also care for children, family caregivers spend almost 24 hours a week caring for a loved one on average, says the Washington, DC-based advocacy group.

Personal caregiving experiences leads to calls for caregiver assistance 

Being family caregivers, both Senators Markey and Capito, primary sponsors of S 3109, like many caregivers, encountered red tape when they attempted to find needed federal caregiving programs and services to care for their parents.

“When my mother suffered from Alzheimer’s, my father was her caregiver in our home in Malden,” remembers Senator Markey. “Caregivers serve on the frontlines of our nation’s health care system by giving our families and friends the care and support they need to remain in their homes and communities with their loved ones. However, our aging and disabled community members can’t get the care they need if their caregivers – the backbone of their treatment – are struggling to navigate complex, burdensome, and stressful processes each and every day while also still managing day-to-day family and professional responsibilities. 

“As a caregiver for my parents during their struggle with Alzheimer’s disease, I know personally the level of responsibility put on family caregivers and the burdens, which can be created by federal process and procedure,” said Senator Capito. “Caregivers in West Virginia and across our country put family first and balance multiple priorities at once, which is why we must do all we can to alleviate roadblocks that could delay and even prohibit them from receiving the support they need,” she said. 

Calls for upper Chamber to pass caregiver proposal

At press time, 32 national aging and health care strongly support passage of S 3109.

“Family caregivers are the backbone of our nation’s long-term care system, and they are overwhelmed with their responsibilities and time spent managing their loved one’s care,” said Executive Vice President and Chief Advocacy and Engagement Officer Nancy LeaMond. “The Alleviating Barriers for Caregivers Act could help save family caregivers valuable time and reduce their stress by making it easier to navigate resources, eligibility, benefits, and health systems when providing care, she says.  

“Our concern is that these federal caregiver programs are so complicated, they become virtually inaccessible, discouraging family and friends from providing caregiving services. The ABC Act is the first step to holding CMS and SSA accountable for eliminating these barriers to caregiving so people with intellectual and developmental disabilities can live their lives in the community,” said Robin Troutman, Deputy Director at National Association of Councils on Developmental Disabilities.

“The Rosalynn Carter Institute for Caregivers (RCI) supports the Alleviating Barriers for Caregivers Act. Far too often family caregivers are faced with burdensome administrative obstacles in accessing the resources and supports to which they’re due. As system fragmentation is a significant component of caregiver strain, we commend this important first step to better streamline, simplify, and coordinate access across federal programs, said Dr. Jennifer Olsen, CEO of the Rosalynn Carter Institute for Caregivers.

“Being a caregiver to someone living with Alzheimer’s is already an incredibly difficult and emotionally draining job. When you layer on top of it the daunting task of navigating our country’s complex healthcare coverage system, it can become downright overwhelming for even the smartest person. This bill is an important step toward making it easier for caregivers to fully advocate on behalf of their loved ones to ensure they have access to the diagnostic, pharmaceutical, and treatment services they need, said George Vradenburg, Chair and Co-founder of UsAgainstAlzheimer’s.

Congress must come together to support caregivers

Family caregivers across the national  provide 36 billion hours of unpaid care, valued at an estimated $600 billion annually. In the Ocean State, 121,000 family caregivers provide 113 million hours of unpaid care valued to be 2.1 billion. These caregivers need assistance from Congress to access resources to provide care to their loved ones. 

There is 372 days left until the 2024 president elections. AARP research tells us that a majority of voters, 78%, are either a current, past, or future family caregiver. Over 70% of voters across the political spectrum say they would be more likely to support a candidate who backed proposals to support family caregivers, such as a tax credit, paid family leave, and more support and respite services.

Hopefully, more Senators will see the value of S. 3109 and quickly become cosigners. It’s time the newly elected House Speaker Mike Johnson (R-LA) and his caucus put the need of their caregiver constituents first, over their political priorities, and support passage of a House companion measure. The House Problem Solvers Caucus can be instrumental in pushing for the introduction and passage. Time will tell.

For more information about caregiving, go to www.aarp.org/caregiving.

For a copy of the 2022 National Strategy to Support Family Caregivers, go to https://acl.gov/sites/default/files/RAISE_SGRG/NatlStrategyToSupportFamilyCaregivers.pdf