Tag Archives for Medicaid

Palliative Care Can Provide Comfort to Dying Residents

Published in Woonsocket Call on May 10, 2015

           A recently published study, by Brown University researchers, takes a look at end-of-life care in America’s nursing facilities, seeking to answer the question, is knowledge and access to information on palliative associated with a reduced likelihood of aggressive end-of-life treatment?

Brown researchers say when a nursing facility resident is dying, oftentimes aggressive interventions like inserting a feeding tube or sending the patient to the emergency room can futilely worsen, rather than relieve, their distress. While palliative care can pull resources together in a facility to provide comfort at the end of a resident’s life, the knowledge of it varies among nursing directors.  A new large national study found that the more nursing directors knew about palliative care, the lower the likelihood that their patients would experience aggressive end-of-life care.

Susan C. Miller, professor (research) of health services, policy and practice in the Brown University School of Public Health and lead author of the study in the Journal of Palliative Medicine, published March 16, 2015, worked with colleagues to survey nursing directors at more than 1,900 nursing facilities across the nation between July 2009 and June 2010.  The researchers hoped to learn more about their knowledge of palliative care and their facility’s implementation of key palliative care practices.

Knowledge Is Power

According to the findings of the Brown study, the first nationally representative sample of palliative care familiarity at nursing homes, more than one in five of the surveyed directors had little or no basic palliative care knowledge, although 43 percent were fully versed.

“While the Institute of Medicine has called for greater access to skilled palliative care across settings, the fact that one in five U.S. nursing home directors of nursing had very limited palliative care knowledge demonstrates the magnitude of the challenge in many nursing homes,” Miller said. “Improvement is needed as are efforts to facilitate this improvement, including increased Medicare/Medicaid surveyor oversight of nursing home palliative care and quality indicators reflecting provision of high-quality palliative care,” she said, noting that besides quizzing the directors the researchers also analyzed Medicare data on the 58,876 residents who died during the period to identify the type of treatments they experienced when they were dying.

When researchers analyzed palliative care knowledge together with treatment at end of life, they found that the more directors knew about basic palliative care, the lower likelihood that nursing facility residents would experience feeding tube insertion, injections, restraints, suctioning, and emergency room or other hospital trips. Meanwhile, residents in higher-knowledge facilities also had a higher likelihood of having a documented six-month prognosis.

The study shows only an association between palliative care knowledge and less aggressive end-of-life care, the authors say, noting that knowledge leads to improved care, but it could also be that at nursing facilities with better care in general, there is also greater knowledge.  But if there is a causal relationship, then it could benefit thousands of nursing facilities residents every year for their nursing home caregivers to learn more about palliative care, the authors conclude.

Progress in Providing End-of-Life Care

Virginia M. Burke, J.D. President and CEO of the non-profit Rhode Island Health Care Association, said, “We were gratified that the authors found that most of the nursing directors who responded to their survey gave correct answers on all (43% of respondents) or most (36%of respondents) of the “knowledge” questions on palliative care.  We were also gratified to see that the number of hospitalizations during the last thirty days of life has declined significantly over the past ten years, as has the number of individuals who receive tube feedings during their last thirty days.  The need for continued progress is clear.”

Burke, representing three-quarters of Rhode Island’s skilled nursing and rehabilitation centers, adds, “It is not at all surprising that greater understanding of palliative care leads to better application of palliative care.”

The states’s nursing facilities are committed to providing person-centered end of life care, says Burke, noting that according to the National Palliative Care Research Center, Rhode Island’s hospitals are among the top performers for palliative care.  “We suspect that our state’s nursing facilities are as well.  We would be very interested in state specific results in order to see any areas where we can improve.”

Says spokesperson Director Michael Raia, of Rhode Island’s Health & Human Services Agency, “We need to provide the right care in the right place at the right time for all patients.”

When it comes to nursing facilities, Raia calls for reversing the payment incentives so that facilities are rewarded for providing better quality care and having better patient outcomes.  He notes that the Reinventing Medicaid Act of 2015 reinvests nursing home reimbursement rate savings into newly created incentive pools for nursing homes and long-term care providers that reward facilities for providing better quality care, including higher quality palliative care.

Bringing Resources to Families

With caregiving one of AARP’s most important issues, it’s no surprise that the organization provides a great deal of guidance on palliative care, stressing that “it involves organizations and professionals coming together to meet a person’s needs both in terms of pain management, along with emotional and spiritual perspectives,” said AARP State Director Kathleen Connell.

Connell says that “It’s is truly a team effort in which nursing home staff become key players. The resources are important to patient with chronic and terminal issues. Their families need help, too. So it is important any time we learn more about ways we can address this very important healthcare need.”

Adds Connell, “In Rhode Island, I’m confident that we have nursing homes that are dedicated to easing the difficulty of this particularly stressful stage of life. They give patients and their families enormous comfort. We certainly applaud their compassion and hope the report is helpful anywhere it identifies a need for improvement,” adds Connell.

AARP’s Caregiving Resource Center (http://www.aarp.org/home-family/caregiving/) includes an End of Life section. Check out a specific palliative care resource at  http://assets.aarp.org/external_sites/caregiving/multimedia/EG_PalliativeCare.html

To read the Brown Palliative Care Study go to http://online.liebertpub.com/doi/abs/10.1089/jpm.2014.0393.

Herb Weiss, LRI ’12 is a Pawtucket writer covering aging, health care and medical issues.  He can be reached at hweissri@aol.com.

President’s Budget Addresses Issues of Interest to Seniors

Published in Pawtucket Times on February 27, 2015
President Obama released his 141 page ‘policy and wish list” when he unveiled his politically ambitious FY 2016 budget on Feb 2, not having to worry about running for president in the upcoming 2016 presidential election cycle.

Yes, even inside the Washington Beltway a picture is truly worth a thousand words. Gone is the budget’s plain blue cover replaced by a black and white photo of the Tappan Zee Bridge in New York, an image that projects one of the President’s spending priorities of rebuilding the nation’s infrastructure to create jobs and improve the transportation system.

The $4 trillion presidential budget, a political campaign document outlaying his policies and priorities, would cancel automatic sequestration cuts to domestic and military programs over a 10 year period. According to the New York Times, Obama’s budget proposal would add $6 trillion to the national debt, and the single-year deficit would rise to $687 billion by 2025.

Obama’s FY 2016 budget puts more funding into education, rebuilding the nation’s infrastructure, increased defense spending, along with providing tax relief for America’s middle class while increasing the taxes for corporate America and the wealthy. Political insiders say that Obama’s budget, one that gives to the middle class and assesses higher taxes from corporate America and the wealthy, sets the issues to be surely debated in the upcoming presidential election. .

A Look at Aging Priorities

On her Feb. 3 blog post, Nora Super, executive director of the upcoming White House Conference on Aging, details how the recently released budget proposal will “ensure that older Americans enjoy not only longer but healthier lives.”

As to retirement security, Super notes that the Obama Administration strongly opposes any legislative measures that would privatize the nation’s Social Security program, or slash benefits for future generations or reduce basic benefits to current beneficiaries. Super says that half the nation’s workforce, that’s about 78 million, does not have a retirement savings plan at work. “Fewer than 10 percent of those without plans at work contribute to a plan of their own. The President’s FY 2016 Budget expands retirement opportunities for all Americans to help families save and give them better choices to reach a secure retirement,” she says.

According to Super, Obama’s Budget proposal supports healthy aging by strengthening the Medicare program by “aligning payments with the costs of providing care, along with encouraging health care providers to deliver better care and better outcomes for their patients, and improving access to care for beneficiaries.”

To put the brakes to rising prescription drug costs, Super notes that the President’s Budget proposes to close the Medicare Part D donut hole for brand drugs by 2017, rather than 2020, by increasing discounts from the pharmaceutical industry. The Budget proposal also gives the Secretary of Health and Human Services new authority to negotiate with drug manufacturers on prices for high cost drugs and biologics covered under the Part D program.

Linking nutrition to healthy aging, Super says that Obama’s Budget provides “over $874 million for Nutrition Services programs, a $60 million increase over the 2015 enacted level, allowing States to provide 208 million meals to over 2 million older Americans nation-wide, helping to halt the decline in service levels for the first time since 2010.” Also, Obama’s budget ratchets up funding for supportive housing for very low-income elderly households, including frail elderly, to give these individuals access to human services, she adds. .

Protecting older persons from elder abuse, neglect and financial exploitation, Super blogs that the President’s budget proposal includes $25 million in discretionary resources for Elder Justice Act programs authorized under the Affordable Care Act. “Funding will “improve detection and reporting of elder abuse; grants to States to pilot a new reporting system; and funding to support a coordinated Federal research portfolio to better understand and prevent the abuse and exploitation of vulnerable adults,” she says.

Here’s Super’s take on the Obama budgetary blueprint: “Taken together, these and other initiatives in the Budget will help to change the aging landscape in America to reflect new realities and new opportunities for older Americans, and they will support the dignity, independence, and quality of life of older Americans at a time when we’re seeing a huge surge in the number of older adults.”

In a released statement, AARP Executive Vice President Nancy LeaMond gives thumbs to the president’s efforts to “lower the cost of prescription drugs, promote better care, reward improved outcomes and make health care programs more efficient and less wasteful.” She also expresses her nonprofit group’s support for the President’s budgetary priorities to “create opportunities for the middle class” and his goal “to make saving for retirement easier.”

But, LeaMond expresses concerns that higher premiums, deductibles and copays might shift costs to older Americans. “As the federal deficit continues shrinking, we must find responsible solutions for strengthening critical programs and improving the retirement and overall economic security of current and future generations. We must also look for savings throughout the entire health care system, as the rising cost of health care threatens people of all ages,” she says.

In his statement, President/CEO Max Richtman, of the Washington, DC-based National Committee to Preserve Social Security and Medicare, agrees with LeaMond’s concerns of higher premiums, deductible’s and co pays, too. “While some tout increasing means testing in Medicare as a way to insure ‘rich’ seniors pay their share, the truth is, the middle-class will take this hit as well,” he predicts.

Political pundits say that Obama’s 2016 budget was dead-on arrival at Capitol Hill the day it was released at the beginning of February. In the shadow of the upcoming 50th Anniversary of Medicare, Medicaid, and the Older Americans Act, as well as the 80th Anniversary of Social Security, GOP leadership in both chambers of Congress must work with the Democratic President to hammer out a bipartisan compromise. Putting budgetary proposals that strengthens the nation’s programs and services for older Americans on the chopping block for purely political reasons is not acceptable, especially to a nation that opposes political gridlock.

Herb Weiss, LRI ’12, is a Pawtucket-based writer covering aging, health care and medical issues. He can be reached at hweissri@aol.com.

GAO Study Reports New Trends Push Older Women into Poverty

Published in Pawtucket Times, March 7, 2014

Following on the heels of a Government Accountability Office (GAO) report released last week on March 5, the U.S. Senate Special Committee on Aging held a hearing to put a Congressional spotlight on the alarming increase of older Americans becoming impoverished.  The GAO policy analysts concluded that a growing number of the nation’s elderly, especially women and minorities, could fall into poverty due to lower incomes associated with declining marriage rates and the higher living expenses that individuals bear.

As many as 48 percent of older Americans live in or on the edge of poverty. “While many gains have been made over the years to reduce poverty, too many seniors still can’t afford basic necessities such as food, shelter and medicines,” said Aging Committee Chairman Bill Nelson (D-FL).

Senate Aging Committee Looks at Income Security for Elders

Policy experts told Senate lawmakers on Wednesday that millions of seniors have been spared from abject poverty thanks to federal programs such as Social Security, Medicaid, Medicare, SSI, and food stamps.  The testimony contrasted with the picture painted by House Budget Committee Chairman Paul Ryan (R-WI) earlier this week, who produced a report that labeled the federal government’s five-decade long war on poverty a failure.

Appearing before the U.S. Senate Special Committee on Aging, Patricia Neuman, a senior vice president at the Henry J. Kaiser Family Foundation, stressed the importance of federal anti-poverty programs.

“Between 1966 and 2011, the share of seniors living in poverty fell from more than 28 percent to about 9 percent, with the steepest drop occurring in the decade immediately following the start of the Medicare program,” said Neuman.  “The introduction of Medicare, coupled with Social Security, played a key role in lifting seniors out of poverty.”

Neuman’s remarks were echoed by Joan Entmacher of the National Women’s Law              Center, who credited food stamps, unemployment insurance and Meals on Wheels, along with Social Security, for dramatically reducing poverty among seniors.  The report was highly critical of many programs designed to help the poor and elderly saying they contribute to the “poverty trap.”  Ryan and other House lawmakers have long proposed capping federal spending and turning Medicaid, food stamps and a host of other programs for the poor into state block grants.

Older Women and Pension Benefits

GAO’s Barbara Bovbjerg also brought her views to the Senate Select Committee on Aging hearing. Bovbjerg, Managing Director of Education, Workforce, and Income Security Issues, testified that the trends in marriage, work, and pension benefits have impacted the retirement incomes of older Americans.

Over the last five decades the composition of the American household has changed dramatically, stated Bovbjerg, noting that the proportion of unmarried individuals has increased steadily as couples have chosen to marry at ever-later ages and as divorce rates have risen.  “This is important because Social Security is not only available to workers but also to spouses and survivors.  The decline in marriage and the concomitant rise in single parenthood have been more pronounced among low-income, less educated individuals and some minorities,” she says.

As marriage and workforce patterns changed, so has the nation’s retirement system, adds Bovbjerg.  Since 1990, employers have increasingly turned away from traditional defined benefit pensions to defined contribution plans, such as 401(k)s, she says, this ultimately shifting risk to individual employees and making it more likely they will receive lump sum benefits rather than annuities.

These trends have affected retirement incomes, especially for women and minorities, says Bovbjerg, that is fewer women today receive Social Security spousal and survivor benefits than in the past; most qualify for benefits on their own work history. While this shift may be positive, especially for those women with higher incomes, unmarried elderly women with low levels of lifetime earnings are expected to get less from Social Security than any other demographic group.

According to Bovbjerg, these trends have also affected household savings Married households are more likely to have retirement savings, but the majority of single-headed households have none. Obviously, single parents in particular tend to have fewer resources available to save for retirement during their working years.  With Defined Contribution pension plans becoming the norm for most, and with significant numbers not having these benefits, older Americans may well have to rely increasingly on Social Security as their primary or perhaps only source of retirement income.

Inside the Ocean State

Although the GAO report findings acknowledge a gender-based wage gap that pushes older woman into poverty, Maureen Maigret, policy consultant for the Senior Agenda Coalition of Rhode Island and Coordinator of the Rhode Island Older Woman’s Policy Group, observes that this inequity has been around since the 1970s when she chaired a legislative commission studying pay equity. “Progress in closing the gender wage gap has stagnated since 2000 with the wage ratio hovering around 76.5 percent”, she says.

GAO’s recent findings on gender based differences in poverty rates are consistent with what Maigret found researching the issue for the Women’s Fund of Rhode Island in 2010.  She found that some of the differences in the Ocean State can be attributed to the fact that older women are far less likely to be married than older men.  Almost three times as many older women are widowed when compared to men.

Maigret says that her research revealed that older women in Rhode Island are also less likely to live in family households and almost twice as likely as older men to live alone. Of those older women living alone or with non family members an estimated one out of five was living in poverty. For Rhode Island older women in non-family households living alone, estimated median income in 2009 was 85% that of male non-family householders living alone ($18,375 vs. $21,540).

Finally, Maigret’s report findings indicate that around 11.3 percent of older Rhode Island women were living below the federal poverty level as compared to 7.3 percent of older men in the state. Older women’s average Social Security benefit was almost 30 percent less than that of older men and their earnings were only 58 percent that of older men’s earnings.

             There is no getting around peoples’ fears about outliving their savings becoming a reality if they live long enough,” said AARP Rhode Island State Director Kathleen Connell. “One thing that the latest statistics reveals [including the GAO report] is the critical role Social Security plays when it comes to the ability of many seniors to meet monthly expenses. Social Security keeps about 38 percent of  Rhode Islanders age 65 and older out of poverty, according to a new study from the AARP Public Policy Institute.”

“Nationally, figures jump off the page,” Connell added. “Without Social Security benefits, 44.4 percent of elderly Americans would have incomes below the official poverty line; all else being equal; with Social Security benefits, only 9.1 percent do, she says, noting that these benefits lift 15.3 million elderly Americans — including 9.0 million women — above the poverty line.”

“Just over 50 percent of Rhode Islanders age 65 and older rely on Social Security for at least half of their family income—and nearly 24 percent rely on Social Security for 90 percent of their family income” states Connell.

             “Seniors trying to meet the increasing cost of utilities, prescription drugs and groceries would be desperate without monthly Social Security benefits they worked hard for and planned on. As buying power decreases, protecting Social Security becomes more important than ever. Older people know this; younger people should be aware of it and become more active in saving for retirement. Members of Congress need to remain aware of this as well,” adds Connell.

Kate Brewster, Executive Director of Rhode Island’s The Economic Progress Institute, agrees with Maigret that older women in Rhode Island are already at greater risk of poverty and economic security than older men.   “This [GAO] report highlights several trends that make it increasingly important to improve women’s earnings today so that they are economically secure in retirement.  Among the “policy to-do list” is shrinking the wage gap, eliminating occupational segregation, and raising the minimum wage. State and federal proposals to increase the minimum wage to $10.10 would benefit more women than men, demonstrating the importance of this debate to women’s economic security today and tomorrow.”

House Speaker Gordon Fox is proud that the General Assembly in the last two legislation sessions voted to raise minimum wage to its current level of $8 per hour.  That puts Rhode Island at the same level as neighboring Massachusetts, and we far surpass the federal minimum wage of $7.25, he said.  He says he will carefully consider legislation that has been introduced to once again boost the minimum wage.

“Bridging this gap is not only the right thing to do to ensure that women are on the same financial footing as men, but it also makes economic sense”, says Rep. David N. Cicilline.  At the federal level, the  Democratic Congressman has supported the ‘When Women Succeed, America Succeeds’ economic agenda that would address issues like the minimum wage, paycheck fairness, and access to quality and affordable child care. “Tackling these issues is a step toward helping women save and earn a secure retirement, but we also have to ensure individuals have a safety net so they can live with dignity in their retirement years,” says Cicilline.

With Republican Congressman Ryan in a GOP-controlled House, captured by the Tea Party, leading the charge to dismantle the federal government’s 50 year war on poverty, the casualties of this ideological skirmish if he succeeds will be America’s seniors.  Cutting the safety net that these programs created will make economic insecurity in your older years a very common occurrence.

.             Herb Weiss, LRI ’12, is a Pawtucket writer who covers aging, health care and medical issues.  He can be contacted at hweissri@aol.com.