Friday, June 24, 2011

Medicare, CMS, Hospitals, and Unnecessarily Institutionalization.

Medicare, CMS, Hospitals, and Unnecessarily Institutionalization. Information Bulletin # 334 (6/2011).

There’s been a number of news articles recently stating that CMS will track hospital spending for Medicare recipients and will reward hospitals that keep costs down and penalize hospitals for costs incurred within 90 days after the person leaves the hospital.

It’s a “Medicare spending per beneficiary” device to measure hospital performance. For example, we have national data for infections occurring after surgery and/or as a result of just being in a hospital. Hospitals with much higher rates will be penalized. Similarly, there’s national data for heart attack mortality rates against which hospitals can be compared, rated, and then rewarded or penalized.

Obviously, besides improving medical care, rewards/penalties are an important strategy to control health costs, something everyone agrees is necessary.

We have a simple suggestion for CMS.

How about CMS including in its “Medicare spending per beneficiary” the measure of placement in nursing homes directly from acute care hospitals? This could actually be easily implemented because CMS could actually enforce its own federal regulations which require hospitals to do real and meaningful “discharge planning”?

CMS has national data by hospital. The federal “discharge planning” regulations require hospitals to identify at an “early stage of hospitalization” people likely to need post-hospital services. Discharge plans must include “appropriate arrangements for post-hospital care ... before discharge.”

Here’s a radical idea - save federal funds, both Medicare and Medicaid, by using the existing regulations to reward and penalize hospitals which do not arrange for home and community-based services and which have higher rates of nursing home placement.

Yes, stop the dumping of people from hospitals to nursing homes. It is outrageous, let alone unnecessarily expensive, that more than 60% of people in nursing homes come directly from acute care hospitals.

It’s no secret that hospital discharge planning does not take home and community-based services seriously. It’s no secret that a primary goal of the hospital is to save money, especially if its nonreimburseable. Therefore, hospitals will do everything to get the person “out of the hospital” as soon as the reimbursements will likely cease, even if it means dumping the person in a nursing home.

CMS - you have a financial interest, the regulatory authority, as well as an interest in the ADA’s mandate that services be provided “in the most integrated setting appropriate,” to address hospital dumping.

Include in the “Medicare spending per beneficiary” plan a measure of post-hospital placements. Reward hospitals that place people in the community with services and penalize hospitals with the worst dumping scores.

Steve Gold, The Disability Odyssey continues

Back issues of other Information Bulletins are available online at with a searchable Archive at this site divided into different subjects. Information Bulletins are also be posted on my blog located at
To contact Steve Gold directly, write to or call 215-627-7100.

Monday, June 6, 2011

180,000 Housing Voucher Turnovers and Transitioning People Out of Institutions.

180,000 Housing Voucher Turnovers and Transitioning People Out of Institutions. Information Bulletin - # 334 (6/2011)

Nationally, in 2010, about 9 percent of nearly 2 million Housing Choice Vouchers (a/k/a Section 8 vouchers) are “turned over” each year. In HUD parlance, these are classified as an“attrition rate.”

Public Housing Authorities throughout the country, therefore, have “turned over” Housing Choice Vouchers available to issueto people who have previously applied for vouchers but were placed on a “waiting list.”

Please be aware that some Housing Authorities may not be able to immediately reissue all vouchers as they turnover. PHAs must manage their program withing the funding that is available, which may preclude them from immediately reissuing all vouchers upon turnover.

As you know, because there are long “waiting lists” for these vouchers, many advocates understandably are discouraged with the length of time people must wait until a voucher becomes available.

However, it’s very important to remember that these “waiting lists” do move nationally by about 9 percent a year. Some Housing Authorities had 20 - 40 % turnover rate. (Please note turnover data was not available for about 25 “Moving to Work” Housing Authorities, many of which are the large Housing Authorities.)

But a 9% turnover rate means, nationally, there are at least (remember the big MTW authorities are not even included) about 180,000 vouchers potentially available to be issued to people who are on a waiting lists.

If you want to see what the “attrition rate”/ “turnover rate” was for you Housing Authority and if you have excel on your computer, go to the following link: or go to The Housing Authorities are by State and the column “units” mean vouchers. If your Housing Authority is not listed, it means either it is one of the 25 MTW authorities or it does not administer any Housing Choice Vouchers.

It’s also important to remember that each Housing Authority may establish preferences for admission to their voucher program. If they do so, they must list the “preferences” for their vouchers in their Section 8 Administrative Plan, which is publicly available. “Preferences” mean exactly what you think. Some categories of people go to the top of the waiting list and others do not.

“Preferences” are supposed to reflect housing “needs” in your community.

In Information Bulletin # 329 (4/4/2011), we summarized the national HUD report entitled “Worst Case Housing Needs of People with Disabilities.” Here is the web link

This Worst Case report does not include persons who are institutionalized in nursing homes, ICFs or Mental Institutions. Advocates know there are many people institutionalized solely because they cannot afford to pay for housing in the community. The nursing home is the Poorhouse of the 21st Century.

What advocates should do:

Advocates for older and disabled Americans should use the HUD “Worst Case” report as a basis for establishing your local “Worst Case Housing Needs of People with Disabilities” in your specific county or city.

Obviously, you must include people who are institutionalized to show that persons in institutions are the Worst of the Worst Cases.

You can now approach your Housing Authorities, persuade them that institutionalized people must be give the highest Preference or at the least a certain number of new admissions each year that will be given preference.

Demand that a certain number of Housing Voucher “turn overs”/ “attrition rates” be used to transition people out of these institutions.

Remember, that annually Housing Authorities must write an Annual Plan which is then submitted as part of a Consolidated Plan. These are supposed to reflect housing needs.

Does your Housing Authority (including the 25 MTW authorities) give a “preference” for persons with disabilities who are in institutionalized because they cannot afford to live in the community? Does it even list these people as having a “need.”? Have you met with your Housing Authority officials to discuss revising their Voucher “preferences” so that people with disabilities in institutions become a high preference? Have you discussed potentially use these Vouchers so that people with disabilities could leave the institution?

What about discussing this option with your State Money Follows the Person officials? With your Medicaid officials? With your Governor’s office which wants desperately to save general revenue funds?

Steve Gold, The Disability Odyssey continues

Back issues of other Information Bulletins are available online at with a searchable Archive at this site
divided into different subjects. As of August, 2010, Information Bulletins
will also be posted on my blog located at
To contact Steve Gold directly, write to or
call 215-627-7100.