August 10, 2005

Other Southern States Attempt to Curb Medicaid Costs

A recent article in The Augusta Chronicle documented the ways in which Georgia and South Carolina are dealing with the rising costs of Medicaid in the face of impending Federal cuts. Even without Congressional cuts, many states would still be facing a financial crisis due mainly to the costs of prescription drugs and long term care. These cuts have forced states to develop innovative ways to address the rising needs of individual's health care and less money to fund the programs.

South Carolina has implemented a program that calls for Medicaid recipients to be given personal health care accounts to pay expenses. Patients could then choose an option that they feel would give them the best service for their needs. The South Carolina plan also hopes to slow the growth of the costs of the program by promoting competition among companies offering different plans.

Patients who spend their money wisely could be rewarded by giving them some of the money back or receive some sort of a gift certificate. But this still raises questions about people who do not spend their account well, or still have expenses beyond what they were provided. This system could also encourage people to ignore potentially serious health concerns so that they can keep some money from their account.

Georgia's plan is similar to a Florida model, and turns to managed care program. The state's Department of Community Health selected companies to enroll the state's more than one million Medicaid and PeachCare for Kids patients into the program. The program has divided the state into 6 regions, with each region serviced by a couple different companies that have experience running managed care programs. The state hopes to save tens of millions of dollars by paying the companies a flat rate per patient, but it remains to be seen whether those savings will materialize. The program will stress preventive care and provide primary care physicians, and attempt to educate patients to seek treatment before their illness becomes critical and more costly to treat.

Neither of these programs is perfect, but both make attempts to address this critical issue. The fact remains that something must be done, because the status quo will be inadequate to address the nations healthcare needs in the future.

August 09, 2005

Louisiana Looks to Study Nursing Home Fines

A recent article in The Times-Picayune has addressed the issue of nursing home sanctions in Louisiana.

Louisiana has long been considered to be lax in its enforcement of federal regulations for health care. Louisiana's homes, which often rank toward the bottom on key quality of care indicators, are far less likely to be fined for violations, even those that cause serious injury or death, than their neighboring states. For example, in the last four years, Louisiana's 309 licensed nursing homes have been fined a total of approximately $1.2 million. Over that same time period, Mississippi's 204 homes were fined $3 million, and Texas's 1,137 homes were fined around $7.4 million.

Some officials in Louisiana are beginning to investigate whether more stringent penalties will lead to better quality of care. Governor Blanco's Health Care Reform Panel spent months studying the state's long term health care program, and recommended that sanctions be increased and that the issue receive more study.

The study will be headed by the state's ombudsman for long term care, Linda Sadden. The group will also include state health regulators, representatives from the nursing home industry, advocacy groups and elderly and disabled people receiving long term care. Sadden has said that they will look at other states for guidance and see if the increased sanctions lead to an increase in the quality of care.

Sadden has said that while relatively little research has been done on the relationship between penalties and quality of care, the few studies that have been conducted suggest that strict sanctions serve as a motivator for nursing homes to improve. In California, for example, the maximum penalty was raised to $25,000 in 1999, and then again to $100,000 in 2001. Following these increases, the number of homes cited for serious violations has dropped from 30 percent to 6 percent in the last six years.

Some have cautioned against stricter penalties, suggesting that higher fines levied will reduce the monies available to provide a high quality of care. Others have countered that if the home is already providing a high quality of care, the increased sanctions will not be an issue.

The group meets for the first time on August 18. It will be interesting to see if this study leads to any dramatic changes in enforcement in Louisiana.

August 07, 2005

Random Bits Learned From The IDR Process

First, if you are doing your own IDR rebuttal, make sure that every page from a resident's chart (even if it is a back page) has the resident's name and a date on it. Second, make sure the names and dates are legible.

Many times, a facility's defense to treatment issues is the fact that the resident or responsible family members refused treatment or diagnostic tests. This defense will not fly unless you are able to demonstrate informed consent on the part of the resident or responsible family members. Thus, if the resident refuses labs that may, for instance, detect problems with dehydration--it is important that the physician clearly informs the resident or family members of the risks of refusing such labs.

If you are trying to administer medication , and he says "I don't want it", inform him of the possible consequences of not taking is medication. Then document the chart with the information and his response.

If you don't have this sort of information in the chart, you won't win on this issue.

July 27, 2005

Legislative Update July 27, 2005

Senate Bill 1525 recently passed and established a number of protocols that must be followed in regard to the safe handling of residents. The bill requires that the quality assurance committee of a nursing home must adopt strategies to control the risk to patients and nurses associated with lifting, moving, or otherwise repositioning the residents. At a minimum, the process must include:
  1. Analysis of the risk of injury to both patients and nurses posed by the environment in which a patient must be handled or moved;
  2. Education of nurses in the identification, assessment and control of risk of injury associated with handling;
  3. Evaluation of alternative ways to reduce risks associated with handling;
  4. Restrictions, if possible, of manual patient handling unless it is an emergency;
  5. Collaboration with and reporting annually to the nurse staffing committee;
  6. Procedures for nurses to refuse to perform a handling that the nurse in good faith believes would pose a risk the the nurse or patient;
  7. Submission of an annual report to the quality assurance committee on activities related to assessment and strategies to control the risks associated with lifting and movement; and
  8. Consideration in any future building projects for incorporating handling equipment or increased physical space.

This act will become effective on January 1, 2006.

Diabetes Causes Concern in LTC Facilities

A recent article in Yahoo News emphasized how critical diabetes care has become to ensuring a high quality of care in nursing homes and assisted living facilities. Diabetes is the fifth deadliest disease in America, and it afflicts a disproportionate amount of older Americans. Half of all diabetes cases involve individuals over the age of 55, and over a quarter of the residents in LTC facilities suffer from the disease. The American Diabetes Association (ADA) estimates that nearly 1 in 5 people over 60 has diabetes. Due to its prevalence in nursing homes and other similar facilities, approximately 10% of healthcare costs are associated with the disease.

With the technology changing and the nature of the disease, it is important that a facility regularly monitor their diabetes management program. The ADA suggests that facilities use the following steps to evaluate their diabetes management programs:

-- Assess the current diabetes situation
-- Screen high-risk patients who have not been diagnosed with diabetes
-- Order appropriate lab tests to determine the resident's condition
-- Assess the patient's hyperglycemia and identify the cause
-- Confirm diabetes diagnosis
-- Evaluate the nature and severity of diabetic complications
-- Obtain input from staff who have worked with the resident
-- Summarize the patient's condition
-- Develop an individualized care plan and define treatment goals
-- Address causes and complications with the resident and caregivers
-- Use oral hypoglycemia agents or insulin as necessary
-- Implement the care plan
-- Re-evaluate the patient at regularly scheduled intervals
-- Routinely monitor the patient's blood glucose levels

It is also important for healthcare facilities to stay abreast of any developments in the field. Continuing education programs and open communication will both help to increase awareness and improve treatment of diabetes.

For more information please click here.

July 19, 2005

The Compassion of Hospice: Dame Cecily Saunders

I wrote yesterday of the passing of Dame Cecily, the founder of modern hospice. Today, I find a beautiful article by Wesley J. Smith about the purpose of hospice as envisioned by Dame Cecily. Click here to read the article.

July 18, 2005

Founder of Hospice, Dame Cicely Saunders, Dies

Dame Cicely Saunders has died in the hospice she founded.

Dame Cicely Saunders, who died yesterday aged 87, was regarded as the mother of the modern hospice movement; at St Christopher's Hospice, Sydenham, south London, founded in 1967, she charted new approaches in techniques for treatment of the terminally ill, based on her Christian belief that no human life, no matter how wretched, should be denied dignity and love.


Cicely Saunders first had the idea of creating a modern hospice in 1948, when she was working as a lady almoner (medical social worker) at St Thomas's Hospital in London. There she met David Tasma, a young Polish waiter who, having escaped from the Warsaw ghetto, was dying of cancer, in great pain, on a ward she was visiting.

Though he had little English, they spent their time together talking about death and the care of the dying: "He needed to make his peace with the God of his fathers, and the time to sort out who he was," she recalled. "We discussed the idea of somewhere that could have helped him to do this better than a busy hospital ward."

Cicely Saunders fell deeply in love and, when he died, he left her all he had - £500 - and told her: "I'll be a window in your home." "It was as though God was tapping me on the shoulder and telling me 'You've got to get on with it'," she recalled.

Carrying Tasma's memory with her, Cicely Saunders became a physician and went on to found St Christopher's Hospice, where she hoped to "help the dying to live until they die and their families to live on". She had no new drugs, but showed how, by using them earlier in anticipation of, rather than in response to, the onset of pain, terminally ill patients could be kept comfortable until the end.

What a great lady. We owe her a debt of gratititude. (HT Wesley J. Smith)

State Governors Gather to Discuss Medicare

According to the Associated Press, a number of governors gathered on Sunday to discuss a number of national concerns, chief among them the budget concerns over rising Medicare expenses. Some governors believe that the President's new policy changes will unfairly require the states to pick up a large portion of the new prescription drug benefit.

A significant portion of the discussions focused on a small part of the new policy dealing with individuals old enough to qualify for Medicare and poor enough to qualify for Medicaid. The states want the federal government to absorb the expenses for this group of individuals, which are significantly larger than the rest of the Medicaid population.

According to some governors, a number of states are contemplating a lawsuit against the government, while others are hoping for a settlement. Governor Rick Perry of Texas has already vetoed the $444 million that was budgeted to be sent to the federal government during the next two years, and has urged fellow governors to discuss changing the federal policy. Vermont's governor has acted similarly, setting aside the $43 million his state would owe until a decision is made on who pays for these services.

The governors say they have the support of all 50 governors in seeking to implement experimental programs with the aims of slowing the growing cost of Medicaid and developing more effective ways to deliver health care. One idea proposed would allow states to collect a copayment from recipients, and some programs would offer incentives (such as quitting smoking or losing weight) that would reduce or eliminate that copayment. The governors believe that they need to come up with a bipartisan plan that is possible before we can hope that Congress could reach such a consensus.

July 14, 2005

Unintended Consequences

Back last November, I wrote about rumblings in Florida to require criminal background checks on prospective resident. In Illinois, they've apparently passed such a law and are now about to suffer the consequences:

Emergency rules implementing the recently signed legislation require all 100,000 current nursing home residents to undergo a criminal background check and be checked against sex offender databases maintained by the Illinois State Police and the Illinois Department of Corrections. The same requirements apply to new admissions.


A spokeswoman for a statewide nursing home association said the new rules are going to turn a delicate family decision into a gut-wrenching experience.
"It's difficult enough to decide to put an elderly relative in a nursing home," said Pat Comstock of the Illinois Health Care Association. "But then to have your elderly grandmother or grandfather subjected to a criminal background check is even more difficult."

And then there is this:

Although the State Police and DOC databases can be easily checked from any computer equipped with Internet access, requests for criminal background checks submitted electronically to the State Police can take up to three days and cost $10. If submitted manually on paper, they can take up to a few weeks and cost $16, according to State Police spokesman Rick Hector.

More than 50 percent of new admissions to nursing homes come directly from hospitals, Comstock said. (emphasis added)

Do you think those hospitals will keep the patients for the days (or weeks) it will take to do this check?

A Discovery in the Fight Against Alzheimers & Dementia

The Washington Post is reporting that a new study may have identified a protein linked to memory loss:

Some recovery of memory may be possible in the early stages of Alzheimer's disease, suggests a provocative new study in mice that could help researchers open a two-pronged attack against the mind-robbing illness.
The research shows a mutant protein named tau is poisoning brain cells, and that blocking its production may allow some of those sick neurons to recover. It worked in demented mice who, to the scientists' surprise, fairly rapidly regained memory.
The work is years away from being useful in people. There are no drugs yet to block tau, and most of the recent search for Alzheimer's treatments has focused instead on another protein, called beta-amyloid.


It's important research because it bolsters the notion of targeting those sick neurons in hopes of one day reversing at least some of dementia's damage, said William Thies, scientific director of the Alzheimer's Association. Today's Alzheimer's drugs only treat symptoms.
"If you can actually rescue some of these sick cells, that really brings the possibility of return of some function, which would be of tremendous value," he said.

Read the whole thing.