Friday, March 23, 2012

Why Does CMS Not Confront the Institutional Nursing Home Bias Against People With Disabilities.

Why Does CMS Not Confront the Institutional Nursing Home Bias Against People With Disabilities. Information Bulletin #353 (3/2012)

The federal agency, the Centers for Medicare and Medicaid Services (CMS), funds virtually every nursing home in the country. Last week, CMS announced a “new initiative” which is aimed “to improve the quality of care for people residing in nursing homes.” However, this “new initiative” will neither prevent institutionalization nor transition people out of nursing homes. Nor does it even address those issues.

What is this “new initiative”? CMS states that “45% of hospital admissions among [nursing home residents] could have been avoided.” That’s 314,000 people with disabilities who reside in nursing homes funded by CMS who, due to the neglect of the nursing homes, wind up needing unnecessary – i.e., preventable -- hospitalizations!

Why has CMS proposed this “new initiative”? To save $2.6 billion in Medicaid and Medicare expenditures which CMS pays for these unnecessary hospitalizations of nursing home residents. The nursing homes do not pay – CMS and your States pay.

Obviously, “unnecessary hospitalizations” should be avoided. Many of these hospitalizations are from bedsores persons in nursing home develop. Why? People with disabilities are not repositioned on a regular basis in nursing homes. Why aren’t they? Take a guess. So CMS has a financial interest in not paying $2.6 billion in hospital costs for the nursing homes’ neglect.

Let’s look at what the CMS “new initiative” to prevent unnecessary hospitalizations will do:

1. “facilitate residents’ transitions to and from inpatient hospitals and nursing homes;”
2. “hire staff … to implement preventive services;” and
3. “work in cooperation with existing providers.”

Okay. Let’s focus on CMS’ financial interest as the primary motivating factor. Here are some suggestions that have been made for years, but for which CMS apparently does not deem important enough to address with a “new initiative.” Each one will produce significant financial savings, the obvious critical CMS motivating factor.

First, about 60.8% of nursing home residents’ admissions come directly from acute care hospitals – that’s 803,743 people. Now these hospitals are required by CMS’ existing federal regulations to do “discharge planning” which is supposed to include community-based services. If this were really happening, then people with disabilities would be offered Medicare and Medicaid services in their own homes and in the community – not forced to go to a nursing home institution without being offered appropriate and adequate community-based services.

Where is the CMS “new incentive” to require acute care hospitals to really do this discharge planning? Why has CMS neither enforced its own existing regulations or developed an incentive so that people in acute care hospitals are at least offered appropriate and adequate services in their own homes and not only in nursing facilities?

Remember, one of the CMS’ “new initiative” proposed interventions to avoid unnecessary hospitalizations is to “facilitate residents’ transitions to and from inpatient hospitals and nursing homes”? Why not the same initiative to facilitate transition from acute care hospitals to our own homes instead of to nursing homes?

Second, the recent AARP Raising ExpectationsScorecard report noted that more than at least 201,531persons with disabilities could be “new users of Medicaid long-term care services” who “would first receive services in their home and community based settings instead of nursing homes.” Yes, at least 201,531 people received their first Medicaid benefits in nursing institutions, instead of in the community.

CMS’ existing regulations require persons with disabilities be offered a real choice before they go into nursing homes. Living in the community instead of a nursing home institution saves big Medicaid money. CMS could save significant funds by enforcing their own regulations.

Remember that one of CMS’ “new initiative” proposed interventions to avoid unnecessary hospitalizations is to “hire staff … to implement preventive services” to avoid unnecessary hospitalizations. Why not a similar initiative to avoid unnecessary institutionalizations?

Third, the same AARP Raising Expectation report notes that there were hundreds of thousands of Medicaid nursing home “residents with low care needs [who could] be able to receive long term services in the community.” Now that’s not a novel idea under the ADA and Olmstead decision. These people are “unnecessarily institutionalized” and could/should be residing in the community with appropriate and adequate services.

Why has CMS not required States to offer these “low care needs” residents appropriate and adequate services in the community? Transitioning people to their own homes, with appropriate and adequate services, saves CMS and States money.

Fourth, the Minimum Data Set identifies persons with disabilities who are in nursing homes who state they want to live in the community. Why does CMS not require each State to end the “unnecessary institutionalization” of these people and make States comply with the ADA and Olmstead decision? CMS could require a very detailed written service plan which lists the specific services, amounts of services, hours, supports, etc., each person could receive in the community? We know the name and address of each of these people.

Remember that one of CMS’ “new initiative” proposed interventions to avoid unnecessary hospitalizations is to “work in cooperation with existing providers.” Why not a similar initiative to transition these people out of institutions? We do not expect the nursing homes to have the desire, interests or knowledge to write these plans. Why not hire ILCs to go into these nursing homes, work with each of these residents, and have the ILCs develop the specific written plan that the State Medicaid office will implement?

Sure CMS should avoid “unnecessary hospitalizations” and save money. But CMS should also avoid “unnecessary institutionalization” in nursing homes and save money.

We know CMS can play hardball when it wants. Recently, it stood up to Texas and cut off $35 million in Medicaid funds for that State’s refusal to provide women on Medicaid with health care services provided by Planned Parenthood.

Each year CMS knows which States have huge and growing waiting lists to prevent people from being unnecessarily institutionalized into nursing facilities and from transitioning out of nursing facilities. This occurs throughout the country. Why does CMS not cut off those States’ nursing home funds the same is it went after Texas?

Disability Advocates - use the AARP Raising Expectations report for your state and tell your newspapers, elected officials, and candidates for office how they can save Medicaid funds while implementing the ADA and Olmstead.

It’s really a sad commentary that CMS has not applied to nursing homes the historically lessons we have learned from institutions for persons with mental illness and for persons with intellectual disabilities.

Steve Gold, The Disability Odyssey continues

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To contact Steve Gold directly, write to or call 215-627-7100. Ext 227.

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