Assessing a Nursing Home
Senator Andrea Nuciforo, Jr.
From the Director
Volunteer of the Year
Ask Elder Services
SHINE Answers

Assessing a Nursing Home

The State of Senior Citizen Home Care Services
By Sen. Andrea F. Nuciforo, Jr.

It is spring in the Berkshires, and the entire county is in full wondrous bloom. In the State House spring means budget season. Budget season is the most hectic time of the year for the legislature, as we begin assembling the revenue and spending plans for the Commonwealth.

The Senate will soon begin deliberations on the FY99 budget. Berkshire seniors and elder advocates have been lobbying for my support of the proposed $6.9 million increase for the Executive Office of Elder Affairs Home Health Service Program. Elder Service organizations throughout the Commonwealth receive the funds allocated for this budget line item for their home care service programs.

Berkshire seniors have expressed great concern over home care funding. The high rate of nursing home placement in Massachusetts and the skyrocketing population growth rate of the 85+ age group explain why this is important to area seniors. In-home care is more cost efficient than nursing homes, and is the preferred choice of most senior citizens. I support the home care service program, and will fight for the full funding of the $6.9 million budget increase.

Marge Lillpopp, a caseworker with Elder Services of Berkshire County, recently took me along for a home visit. I realized the negative effects time constraints have on the caseworker and the client since Medicaid only pays for 3.5 hours of services per week. This is not enough time for the caseworker to assist with all the necessities of life and the client is forced to choose between vital services.
The client I visited is typical of those that rely upon Medicaid assistance; she requires more home care services than what Elder Services is able to supply due to budget confines. The home care service budget increase will enhance the level of care that seniors receive and will help maintain the health, hygiene and irreplaceable independence of living at home.

As your State Senator, I will support the increased funding for home care services, It will allow Elder Services of Berkshire County to spend more money on each senior citizen, significantly improving the level of care. Addressing the concerns of the senior population is, and will remain, a priority for me.

From the Director

From the Director is a reprint from the April 1998 AT HOME, the newsletter of the Mass Home Care Association, of which Elder Services is the Berkshire County member. It explains the squeeze in Medicare services being felt by many who are losing their home health care. (Elder Services is not a Medicare provider; home health services through Medicare are paid only to certified home health care agencies, many of which are Visiting Nurse Associations.)

The Home Care Squeeze

Last fall, the U.S. General Accounting Office issued a report warning that federal regulators were going to have to carefully implement enhanced program controls in the Medicare home health program "to assure that unscrupulous providers cannot readily ‘game' the system." The GAO report helps to explain many of the new restrictions placed on the program by a Congress that should rightfully share some of the responsibility for changes in the system that fueled the rapid growth in home health expenditures.

Meteoric increases in Medicare home health expenditures, from $2 billion in 1989 to almost $18 billion in 1996, coupled with allegedly widespread billing fraud and abuse, led to a flurry of regulatory activity in Congress designed to cut costs and reduce fraud. According to the GAO, "controls over the use of home health care are virtually nonexistent."

The GAO report makes it clear, however, that Congress itself may be to blame for the skyrocketing expenditures on Medicare home health - not the home health agencies. According to the GAO, Medicare home health began in 1966 as a benefit for people recovering from illness or injury after a hospitalization. But over the years, the benefit changed to a "more custodial type care for chronic conditions," says the GAO. "Changes in law and program guidelines have led to rapid growth in the number of beneficiaries using home health care and in the average number of visits per user," the GAO writes. "More patients now receive home health services for longer periods of time."

Such changes, however, were not implemented by home health agencies, but by Congress. In 1980, Congress passed the Omnibus Budget Reconciliation Act, which broadened the original home health benefit. In addition, court cases in the late 1980s expanded the home health benefit, so that today "there is no limit on the number of visits for which Medicare will pay." In 1989, the Health Care Financing Administration issued new guidelines that "essentially transformed the home health benefit from one focused on patients needing short-term care after hospitalization, to one that services chronic, long-term patients as well."

As a direct result of Congressional and regulatory changes, between 1989 and 1993, the percentage of home health patients receiving more than 30 visits increased from 24% to 43%, and those receiving more than 90 visits tripled from 6% to 18%. One-third of the people using home health benefits did not have a prior hospitalization.

The GAO reported to Congress examples of wide-spread abuse of the liberalized rules for Medicare home health. "For example," the GAO said, "a physician called a claims processing contractor to complain that some of his patients were being told by a home health agency that they were ‘homebound' merely because they did not own a car." Other agencies directed staff to alter or falsify records, logging visits that were never made. Operation Restore Trust, a fraud detection auditing program, found that some or all of the services received by 39% of the clients in 74 home health agencies in Texas and Louisiana should have been denied. A similar audit in Massachusetts, however, turned up none of the alleged abuses found in other states. The GAO concluded in its national report that because of very low levels of claims reviews, and limited involvement by doctors in care-planning, it was "nearly impossible to know whether the beneficiary receiving home care qualifies for the benefit, needs the care being delivered, or even receives the services being billed to Medicare."

In reaction, Congress and the White House joined in to enact new payment restrictions, increased funding to reduce fraud and abuse, and even placed a temporary moratorium on the certification of new home health agencies. Most notably, Congress did not change any of the eligibility guidelines for home health care - only the payment system. A new Prospective Payment System (PPS) was mandated, which will eventually base payment to agencies on a fixed, pre-determined amount per unit, and when implemented in the year 2000 will reduce total payments to equal those of the current system if the cost limits were reduced by 15%. In the interim, a temporary payment system has been devised by HCFA that home health agencies in Massachusetts say will reduce home health services by 1.5 million visits, and cut the level of care by $100 million.

It was perhaps inevitable that Congress would invoke strong measures to reign in growth in Medicare home health outlays. But by making the changes on the vendor payment side and stepping up agency audits - but not changing programmatic guidelines - Congress has created a situation in which home health agencies will be forced to cut care to thousands of elders, but never to explain that the real reason for the cutbacks is the new Interim Payment System. Instead, elders are being told that they are no longer "homebound," or that they no longer need skilled nursing care. In order to reduce the level of home health service, and provide care strictly according to the regulations, home health agencies must seek refuge in a more narrow interpretation of the regulations. Home health agencies say they simply don't have enough money to maintain the level of services they had historically provided to consumers.

The net effect is that thousands of elderly consumers in Massachusetts are having their Medicare home health benefit significantly reduced. They can appeal such a reduction, but while their appeal is being reviewed, they are financially responsible for every hour of care they receive. At the rate of $55 to $60 for a home health aide, most elders cannot afford to appeal.

At the state level, a $100 million cutback in Medicare home health means the squeeze is on the state home care program. With only a 1% increase in state funding in Governor Paul Cellucci's FY 99 budget, many home care corporations are seeing a significant increase in referrals for personal care. Advocates will be asking lawmakers to "ease the squeeze" by increasing home care funding.

Rose Crittendon Named Meals on Wheels Volunteer of the Year

Elder Services of Berkshire County is pleased to announce that Rose Crittendon of Otis as won the 1998 Meals on Wheels Volunteer of the Year award. Sponsored by ProjectMeal Foundation and Reynolds Metals Company this national award recognizes individuals who have made significant contributions to Meals on Wheels.

The following is a reprint of the essay describing Rose's commitment to Meals on Wheels:

Rose Crittendon and her friend, Lillian, organized the all volunteer Meals on Wheels route in Otis in 1994. Together, with help from Elder Services of Berkshire County, they established the 10-stop volunteer route so that the homebound elders in this very rural area of Berkshire County could have a hot, nutritious meal delivered each weekday.

In September 1994, Lillian died. She had cancer and knew her death was imminent. Rose promised her friend she would keep the Meals on Wheels route going in Otis. Since Lillian's death, 62 year old Rose has worked tirelessly to recruit and schedule volunteers for the Meals on Wheels route. Health problems make walking difficult for Rose, so most of her work is done by telephone. In addition to organizing the volunteers, Rose keeps meticulous records and faithfully submits them to Elder Services.

This volunteer work is not without its challenges for Rose. Finding volunteer drivers to deliver Meals on Wheels sometimes means spending an entire weekend calling friends and neighbors to persuade them to lend a helping hand. Rose never gives up and she never says she can't find drivers. Rose has commented that many times she feels like "throwing in the towel" but the voice of Lillian echoes in her mind and Rose remembers that she made a promise to her friend, that the community needs her efforts, and that her neighbors need Meals on Wheels.

Elder Services is fortunate to have many volunteers offer their time and energy in areas such as money management, long term care ombudsman, congregate meal sites and SHINE. It is always wonderful when another organization such as Reynolds Metal Company joins us to express our appreciation. For further information about our volunteer programs call Elder Services at 499-0524 or 1-800-544-5242.

Ask Elder Services

Q: My husband is due to have cataract surgery and will be unable to drive for a time, and I don't drive at all. We will need transportation to the grocery store and to a number of doctor appointments. Is there anyone who can help?

A: Transportation can be a serious problem for many seniors. For some it is an on-going, daily problem, and for others the need is short term. Whenever the need for transportation arises, it is critical.

Fortunately there are many agencies throughout Berkshire County that offer transportation services.

Elder Services' volunteers provide rides to seniors who do not need assistance getting in and out of the car. The volunteers drive seniors to doctor appointments, to the bank, pharmacy, nursing home, hairdresser etc.

Local Councils on Aging provide transportation through both volunteers and vans. Some vans are handicap accessible. Many of them have regularly scheduled routes to grocery stores and meal sites.

A senior who is disabled and needs assistance getting in and out of a car may need to use chaircar services. Tickets that reduce the total cost of a chaircar ride are available to eligible seniors at many Berkshire County locations.

For information about transportation in your local area, call Elder Services 499-0524 or (800) 544-5242.

Health Insurance Questions & Answers

Q: I can no longer afford the Medicare supplemental insurance plan that I have carried since I retired. What options are there?

A: There may be several options for you.

Request the list of Medicare supplemental insurances available for sale in Berkshire County. Although prices vary, each company must offer the same coverage under each policy - Core, Supplement 1 and Supplement 2. You may be able to purchase the same health coverage for a different cost from a new insurance company.

Another consideration might be "downgrading" your coverage, changing to another policy with fewer benefits and lower premiums. Before doing this, compare your current premiums with costs you would incur with the new policy. For example, if your current premium is $260 a month, and the policy with less coverage is $150 a month, would your monthly out of pocket costs exceed the $110 difference? If your prescriptions cost less than the $110, you could consider downgrading from Supplement 2 to Supplement 1.

You may be able to enroll in one of the several public health insurance programs. The individual income and asset limits for Medicaid are: $691 or less monthly income, and $2000 or less in assets. Medicaid benefits include many services not covered by Medicare.

If your individual income is less than $691 a month, with no more than $4000 in assets, you may be eligible for the Qualified Medicare Beneficiary Program (QMB). This pays for the gaps in Medicare insurance, including Medicare Part B premiums, Medicare Part A hospital deductibles, Medicare Part A coinsurance for skilled nursing care, Medicare Part B deductible, and Medicare Part B coinsurance.

Another MassHealth program is the Special Low-Income Medicare Beneficiary Program (SLMB). For individuals with monthly income between $691 and $825, with assets no greater than $4,000, SLMB will pay your Medicare Part B premium. Income and asset limits on all programs are somewhat higher for couples. SLMB income limits may rise pending state legislative action, and at the same time two additional programs will be implemented.

Additional programs are available. These include the Senior Pharmacy Program, the Free Care Pool for hospital costs, and the Free Drug Assistance Program. Also, watch in your area for, and take advantage of, free or reduced cost health care clinics and screenings. They do not take the place of regular medical care, but can supplement it. Local hospitals generally provide these services and should be able to provide a schedule. Check with your local VNA for a schedule of their blood pressure clinics.

Q: My income is somewhat above the limits for Medicaid, but I have exceptionally high medical expenses. What should I do?

A: Call the local MassHealth office (413-447-3033 or 3034) and talk with them about your situation. There is a process called "spend-down" that might apply to you. In fact, always call MassHealth if you have any questions about your eligibility for any MassHealth program. SHINE counselors can suggest that you may be eligible, but the decision is always made by MassHealth, after a thorough review of your financial situation.

Q: What are the Senior Pharmacy Program and the Free Drug Assistance Program?

A: The Senior Pharmacy Program is a state-funded program that provides prescription drug coverage, up to $750 per year, for eligible individuals. The individual income limit is $12,084. The program covers many prescription drugs, but coverage cannot be guaranteed. However, individuals who have no other prescription coverage should apply, if they meet the guidelines, because there is no cost for the application, and because the list of covered drugs is growing.

The Free Drug Assistance Program provides some prescriptions, at no cost, to low-income individuals. Each drug company that participates has its own applications and eligibility criteria. They all require participation of your physician. If he or she is unfamiliar with the program, they can speak to the SHINE Coordinator for details.