The old man slept quietly as his daughter sat by his hospital bed. Suddenly, an aide walked in and announced that a move was imminent.
“Your time here is up,” Bonnie Miller Rubin remembers the aide explaining. “He’s going to a nursing home.”
It was 9 p.m., and Rubin’s 91-year-old father had been asleep for several hours. “I said, ‘Are you kidding me?’” Rubin recalled.
“I felt powerless,” she said, remembering her alarm on that cold night three years ago. “What rights did I have?”
In fact, Rubin could have filed a “fast appeal” of her father’s pending discharge with a Medicare Quality Improvement Organization. If she’d made a telephone call on the spot, her father would have stayed in the hospital until an independent physician reviewed his circumstances.
Every older adult admitted to a hospital as an inpatient has the right to challenge a discharge if he or she feels unprepared to leave. But few people understand the process that’s involved.
Frequently, seniors and their families are caught by surprise when a transfer from the hospital is at hand.
“People don’t understand how fast-tracked things get,” said Trish Colucci, a principle care manager with Peace Aging Care Experts in Flanders, N.J. “There’s enormous pressure on discharge teams to get patients out.”NAVIGATING AGING
Navigating Aging focuses on medical issues and advice associated with aging and end-of-life care, helping America’s 45 million seniors and their families navigate the health care system.
To contact Judith with a question or comment, click here.
For more KHN coverage of aging, click here.
After a lawsuit charging that Medicare was not giving beneficiaries adequate notice of the right to appeal pending discharges, the government issued new regulations on the process a decade ago. Here’s how so-called “fast appeals” are supposed to work:
Know your rights. Every older adult admitted to the hospital should get a written notice of their rights — including the right to appeal planned discharges — within two days. If you remain in the hospital for at least five days, you should receive a second notice before being discharged.
This “Important Message from Medicare” will give you the name and a phone number for your Medicare Quality Improvement Organization (QIO) — an entity charged with handling fast appeals as well as other matters, such as complaints about the quality of care.
QIOs serve older adults on traditional Medicare as well as seniors with managed care-style Medicare Advantage plans. Livanta is the QIO for seniors with Medicare who live in the Northeast and the West Coast. KEPRO covers the rest of the country.
Rubin doesn’t remember receiving these notices from Evanston Hospital, just outside Chicago, where her father was being treated for respiratory distress. But Jim Anthony, a hospital spokesman, said the medical center always distributes them, as required.
The medical center began planning the older man’s transition to a nursing home on “the day of admission, with the family’s knowledge,” Anthony explained.
The bottom line: Read all the documents that you’re handed in the hospital. Don’t assume you can put off doing so until later.
Initiating an appeal. If you don’t feel ready to leave the hospital, call the QIO and explain that you’re filing a fast appeal of a pending discharge. You can call during the day or at night up until just before midnight on the day that the discharge was set to occur.
If someone’s not manning the phones — QIOs are open 9 a.m. to 5 p.m. during the work week and 11 a.m. to 3 p.m. on weekends and holidays — leave a message explaining your situation.
A family member or caregiver can initiate the process if a patient is unable to do so. But they may subsequently need to fill out a form clarifying that they can act as the patient’s representative.
Only seniors admitted to the hospital qualify for this appeals process. Patients on “observation status” have a separate appeals process. So make sure you clarify your status often, this might not be clear.
Hold tight. Once a fast appeal has been lodged, you can’t be transferred from the hospital until its resolution. Usually, that takes about two days.
Nor can you be charged for the extra time you spend in the hospital, though coinsurance payments and deductibles will still apply.
The hospital will send a copy of your records to the QIO, to be examined by an independent medical reviewer. You have a right to see these documents, if you so choose. The QIO will contact you and inquire about your discharge concerns.
If the QIO determines that a discharge is appropriate, you can stay in the hospital until noon the next day, at no extra charge. If the QIO overrules the hospital, you can stay until another discharge is proposed.
The standard? Medical care in the hospital must be deemed medically necessary by your physician.
If you’ve stabilized, without symptoms such as a fever, difficulty breathing, or a purulent wound, you’ll probably be considered ready for transfer, said Anne Sansevero, a registered nurse and aging life care specialist in New York City.
Stay informed. It’s a good idea to ask your doctor every day “Is there any update on how long I’m likely to be here?” so you don’t find yourself “in a last minute situation,” said Liz Barlowe, a care manager from Seminole, Fla.
If the hospital hasn’t adequately addressed your need for a “safe discharge,” you may have grounds to contest its decision.
Barlowe described a 78-year-old client who fell and broke her hip when visiting her son and daughter. Preparing for surgery, scans showed that the woman had masses in her uterus and pelvis — cancer.
After hip surgery, hospital staff said they couldn’t bring in a gynecologic oncologist to consult on the older woman’s case, and recommended that she be sent to a rehabilitation center.
Barlowe immediately contacted KEPRO, which overturned the hospital’s decision. Instead, the QIO’s medical reviewer directed that the patient stay there until a cancer specialist provided a consultation and helped to devise a plan of care.
The QIO’s intervention bought the family another 48 hours, during which time they were able to find a facility in Miami able to offer chemotherapy as well as rehabilitation for the woman’s hip. And the patient was able to rest and build up her strength.
Fast appeals similarly exist for hospice, home health, skilled nursing and rehabilitation services, but the rules and time frames involved differ slightly.
KHN’s coverage related to aging & improving care of older adults is supported by The John A. Hartford Foundation.
Joint replacements. Cardiac care. Chemotherapy.
What do those things have to do with the repeal of the Affordable Care Act?
Economists and policymakers think the U.S. may be overpaying for such services, which helps drive up health care expenses for everyone. And the health law has a program that includes testing new ways to pay for care — including in those three areas — that might result in better quality and lower costs.
But with the ACA up for potential repeal, what happens to that testing now? One of the emerging questions is whether Congress will save all or part of that effort, known as the Center for Medicare & Medicaid Innovation.
Republican lawmakers have complained — along with some in the health care industry — that the law under the Obama administration gave too much authority to the head of the Department of Health and Human Services to create and expand projects. Now, however, that very same authority may look appealing as Republicans head the department and may want to use the center to test their own ideas, including those that would revamp Medicare or Medicaid.
“You can dislike that authority, until you have the opportunity to use the authority,” said Rodney Whitlock, a vice president at ML Strategies, a government consulting firm in Washington, D.C., and former Republican staff member of the Senate Finance Committee.This KHN story also ran on NPR. It can be republished for free (details).
As they debate and discuss ways to repeal the Affordable Care Act, lawmakers will weigh the innovation center, funded through the health law with $10 billion for 2011 to 2019, and another $10 billion for each subsequent decade. The Congressional Budget Office estimates the center would increase federal spending initially, but ultimately result in lower costs and save up to $34 billion over the next 10 years.
Congressional Republicans have not yet hinted whether they will keep, modify or kill the program but they generally support the cost-saving goal of the center and many observers think they will want to preserve it.
“If health care providers can do a better job of delivering patient care … at the same or lower costs, that’s the kind of flexibility the system needs more of,” said Mark McClellan, a professor of health policy at Duke University who headed Medicare for two years under the George W. Bush administration.
One group that generally supports the broad cost-saving goal of the center, nonetheless warned that Congress should place limits on it. Otherwise, “there is nothing preventing [the center] from testing a model … that includes all Medicare and/or Medicaid beneficiaries in the U.S,” the Healthcare Leaders for Accountable Innovation in Medicare said in a white paper. “In effect [the center] could test a model that completely restructures the Medicare or Medicaid program.”
Billions of dollars have already been spent by the center, testing a variety of ideas, from ways to improve care for at-home dialysis to ways to foster more collaboration between doctors and hospitals to efforts to reduce unnecessary hospital visits by chronically ill Medicare patients. Many of the efforts look at ways to move from Medicare’s traditional fee-for-service payment system — that economists and policymakers say drive up costs — and instead set up reimbursement that rewards coordinated care. Few of the projects have been in place long enough for the center to determine if they truly save money and improve care.
Even if the center were eliminated, many experts say these types of payment reforms will continue because of private sector interest.
“Pay-for-value is going to be a guiding principle going forward irrespective of who is in power,” said Dan Mendelson, president and CEO of the consulting firm Avalere Health. “It would surprise me to see wholesale U-turn from that policy.”
To date, most of the programs funded by the innovation center are voluntary, but controversy has arisen over several recent initiatives that require participation by doctors or hospitals.
What may happen is that there will be fewer of these mandatory efforts. This year, one such project got underway, testing a method of “bundling” payments for joint replacements at 800 hospitals in 67 metro areas. For their Medicare patients, the project requires a single bundled payment to cover the cost of these procedures, including in-patient and post-operative care, instead of separate payments for each doctor, hospital or nursing home visit. A similar mandatory project for certain kinds of cardiac care has also been proposed.
In the end, the center’s future will be determined by whether the Republican majority believes it is one of the best ways to slow rising medical costs, said Christopher Condeluci, principal at CC Law & Policy in Washington, D.C., and the former tax and benefits counsel to the Senate Finance Committee.
“If the answer is yes, they will keep it and it might go to new heights,” Condeluci said.
But economist Joe Antos, a resident scholar at the American Enterprise Institute, does not think the new administration — or many members of Congress — will push to use the center’s authority to create broad, mandatory nationwide experiments with Medicare.
“I can’t imagine a Trump administration saying we want the bureaucrats to decide on the health care your grandmother is going to get,” said Antos. “Anything that is that much of a marquee issue absolutely has to go through Congress.”
Medicaid Block Grant Would Slash Federal Funding, Shift Costs to States, and Leave Millions More Uninsured
A Medicaid block would institute deep cuts to federal funding for state Medicaid programs and threaten benefits for tens of millions of low-income families, senior citizens, and people with disabilities.
Steven Mnuchin, President-elect Trump’s nominee for Treasury Secretary, said today of Trump’s coming tax cut proposal, “Any reductions we have in upper-income taxes will be offset by less deductions so that there will be no absolute tax cut for the upper class.” But his assertion, on CNBC this morning, is completely at odds with the tax plan that Trump announced during the campaign, which would provide a massive tax cut for upper-income taxpayers.
While supporters of converting Medicaid to a block grant often tout the greater state flexibility it would provide, states already enjoy expansive flexibility under Medicaid, which they’re using to streamline health care delivery and improve health.
Describe your background.
I am a Salvadoran American from North Carolina who loves living in DC. In the year and a half I have been at the Library of Congress, I have moved from the Congressional Research Service to Library Services and now work for the Law Library.
I am a product of North Carolina’s public education from beginning to end. I completed my bachelor’s in dramatic art with minors in women’s studies and Native American studies. I have a dual master’s in library science and public administration. I completed these degrees at the University of North Carolina at Chapel Hill. My internships at NARA (National Archives and Records Administration) and NMAI (Smithsonian’s National Museum of the American Indian) convinced me that I wanted to work for our federal government.
How would you describe your job to other people?
I work on the Indigenous Law Portal doing research on the legal systems of indigenous communities of Central America. One intern described the research work as being Indiana Jones behind a computer. I also do reference and outreach, answering questions and sharing our work with national and international organizations in the form of emails, publications, conference presentations and posters. I work in a very particular niche that combines my indigenous studies with my native language of Spanish as well as both of my graduate degrees. I am a lucky person because I am the only person in the entire Library of Congress who does what I do.
Why did you want to work in the Library of Congress?
I want to serve a global public at a world class institution. We are respected as a politically neutral entity whose commitment is to enlightenment through knowledge and research. Our breadth and depth allows us to do incredible things. Whether I am doing online research, working with experts, or sharing my work with international librarians at the International Federation of Library Associations and Institutions (IFLA) conference, for example, or indigenous leaders at the Organization of American States, I am conscious of how privileged I am to represent the Library of Congress.
What is the most interesting fact you have learned about the Law Library of Congress?
I am impressed by the worldwide focus. There are important historical works as well as modern items from every country. Over 400 titles were digitized for the Indigenous Law Portal so the collection includes tribal law, non-western law. The Law Library is truly a treasure trove.
What’s something most of your co-workers do not know about you?
I perform and direct plays in the D.C. area. I have created an artistic activist community for myself and get to use a different part of my brain when I leave work. I love living in D.C. because all facets of me can flourish.
Efforts to strengthen the country’s tattered mental health system, and help millions of Americans suffering from mental illness, are getting a big boost this week, thanks to a massive health care package moving through Congress.
Key provisions from a mental health bill approved last summer by the House of Representatives have been folded into the $6.3 billion 21st Century Cures Act, which aims to speed up drug development and increase medical research. The act also would provide $1 billion in the next two years for prevention and treatment of opioid addiction.
The legislation aims to make mental health a national priority and coordinate how mental health care is delivered, said Rep. Tim Murphy, R-Pa., a psychologist who treats patients with PTSD and traumatic brain injuries at the Walter Reed National Military Medical Center in Bethesda, Md. Murphy, the mental health bill’s author, said it places a strong emphasis on science, pushing federal agencies to fund only programs that are backed by solid research and to collect data on whether patients are actually helped. Among other provisions, the bill pushes states to provide early intervention for psychosis, a treatment program that has been hailed as one of the most promising mental health developments in decades.
Murphy began researching how to improve the mental health system after the Newtown shootings in 2012, which raised awareness about the problem of untreated mental illness. He introduced his bill the following year. “That horror is etched on our collective memories,” Murphy said Tuesday at a committee meeting of the House Rules Committee.This KHN story also ran in USA Today. It can be republished for free (details).
The House of Representatives is scheduled to vote on the Cures Act Wednesday, with a vote in the Senate expected next week. Although the health care package has strong support, its passage is not assured. Sen. Elizabeth Warren, D-Mass., has said the bill favors the pharmaceutical industry at the expense of patient safety. Heritage Action for America, a conservative group, also opposes the bill because it would increase federal spending.
Many advocates for the mentally ill praised the bill.
“The mental health field has lagged way behind other health disciplines in identifying services that really work,” said Ronald Honberg, national director of policy and legal affairs at the National Alliance on Mental Illness. Honberg called the bill’s mental health provisions “necessary and promising.” He said he appreciated the bill’s focus on “preventing the most horrific consequences of untreated mental illness,” including homelessness, incarceration and suicide.
Dr. T. Scott Stroup, a professor of psychiatry at Columbia University College of Physicians and Surgeons in New York, said he was encouraged by the focus on “evidence-based treatment, rather than ideology- or opinion-based treatments.” That focus “will prevent people from wasting time on treatments that don’t work,” Stroup said.
The bill generally requires states to use at least 10 percent of their mental health block grants on early intervention for psychosis, using a model called coordinated specialty care, which provides a team of specialists to provide psychotherapy, medication, education and support for patients’ families, as well as services to help young people stay in school or their jobs. Research from the National Institutes of Health shows that people who received this kind of care stayed in treatment longer; had greater improvement in their symptoms, personal relationships and quality of life; and were more involved in work or school compared to people who received standard care.
The bill also sets up a $5 million grant program to provide assertive community treatment, one of the most successful strategies for helping people with serious mental illnesses, such as schizophrenia. Like the early intervention program, assertive community treatment provides a team of professionals who are on call 24 hours a day. The bill also expands a grant program for assisted outpatient treatment, which provides court-ordered care for people with serious mental illness who might otherwise not seek care.
Although the bill authorizes these grants, a future Congress would have to approve funding for the programs. “The fact that a program has been authorized is no guarantee that it will be funded,” Honberg said. “It’s a necessary first step.”
If the bill passes, mental health advocates will lobby for Congress to approve funding for the most critical programs, Honberg said.
Other sections of the bill, based on legislation introduced by Sen. John Cornyn, R-Texas, give communities more flexibility in how they use federal grants. For example, communities could use community policing grants to train law enforcement officers to deal with patients in the midst of a psychiatric crisis. Another provision would require the U.S. Attorney General to create at least one drug and mental health court pilot program, which aim to help people with mental illness or drug addiction receive treatment, rather than jail time, after committing minor offenses.
The bill recognizes that “we have a crisis in the way we treat serious mental illness and we’re doing to do something about it,” said John Snook, executive director of the Treatment Advocacy Center, which advocates on behalf of people with serious mental illness. “It takes all the best ideas in criminal justice and mental health and makes sure the federal government is supporting them.”
The mental health provisions have been in the works for nearly four years. Murphy acknowledged that some key provisions in his original bill were removed in order to garner broader support. “We didn’t get everything we needed, but we needed everything we got,” he said.
An earlier version of the bill would have changed a federal privacy law to allow doctors, under certain circumstances, to share mentally ill patients’ medical information with their family caregivers. Murphy said the change was needed, because doctors today often shut families out of their loved one’s care, refusing to share even basic information, such as appointment times, for fear of violating the Health Information Portability and Accountability Act, or HIPAA. Many health professionals misunderstand the law, refusing to even listen to the families of patients who are too disabled by psychosis to provide key details of their medical history.
Some advocates for the disabled objected to that change, however, arguing that patient privacy is essential, and that people might avoid care if they don’t believe their doctors might disclose confidential information.
The new bill simply instructs the Secretary of Health and Human Services to clarify when doctors can share patients’ medical information with family caregivers, as well as educate health care providers about what the law actually says.
“It’s a step in the right direction,” Honberg said. “There is so much misinformation about HIPAA. It’s one of the most mischaracterized laws out there.”
The bill also aims to better coordinate mental health care. Although eight federal agencies today fund 112 programs that provide mental health care, these agencies rarely coordinate their efforts to make sure patients get the help they need and to avoid duplicating services, Murphy said.
The bill would make structural changes to the way federal agencies provide mental health services.
- A new committee would link leaders of key agencies involved in mental health care, such as the Department of Veterans Affairs, the Department of Justice and the Substance Abuse and Mental Health Services Administration, or SAMHSA.
- A new position — the Assistant Secretary for Mental Health and Substance Use — would oversee SAMHSA and disseminate the most successful approaches to treating mental illness.
- An advisory board, the National Mental Health and Substance Use Policy Laboratory, would also analyze treatments and services to help decide which ones should be expanded.
“We want the states to tell us what makes a difference, so other states can benefit from their success and learn from their failures,” Murphy said. “Let’s fund programs that work and keep them going.”