Medicaid Reimbursement – Yet Another Puzzle Piece

Elderpride: Chapter 5


In a similar fashion to Medicare, Medicaid also reimburses nursing homes for care of patients and residents. I have an opinion about what makes an individual a resident of a nursing home rather than a patient. Shouldn’t nursing home care be transitional? And resident implies that this is where you live! I don’t want to live in a nursing home! Do you? I don’t want to be a resident! Do you? So in this blog we will always refer to individuals being treated in nursing homes or skilled nursing facilities as patients.

Medicaid is partially funded by revenue sharing to the 50 states from the federal government. The individual states also provide funding to the program. And the individual states are able to determine who qualifies and who does not although there are some broad federal requirements as well. Medicaid is basically healthcare provided for low income populations with a focus on children, pregnant women and the elderly. Therefore states may differ in who qualifies for Medicaid and who does not. The view I am giving here is a global view and there may be differences state to state. I encourage you to check your individual state requirements by searching on “Medicaid your state”.

Medicaid basically covers non-rehabilitative and unskilled care for elderly persons. This means care that usually can be given by an untrained person. No education or licensing is required for unskilled care. Some of the non-rehabilitative care may be given by licensed practical nurses, however it is not at the same level as skilled care covered by Medicare and does not cover therapies. Most states require that the individual is poor. This means if you are not, then you will need to spend down your assets to a specified level. In my own state, if there is a spouse then an individual can have a house, a car and enough money in the bank for burial – and that is all. If they individual does not have a spouse then they can only have enough money in the bank for burial. A patient must apply for Medicaid and qualify in order to receive these benefits. Once approved, however the individual is a Medicaid recipient.

Once an individual spends down their assets, they have fewer choices about their care. The patient (Medicaid recipient) is totally dependent upon the system at this point and if the system fails them, they are doomed. They will have no funds to implement another solution.

The reimbursement system works much like Medicare in that the nursing home completes a claim for services rendered and submits it to the appropriate state office. The claim is reviewed and either approved or denied. A denial can be appealed. However the similarity ends there. Medicaid coverage is much less of a mystery and the provider (nursing home facility) usually knows what is covered in advance because it is much more “cut and dried”. Therefore, there are fewer denials. Consider however that we are talking fewer dollars because skilled care is not covered by Medicaid and unskilled care is paid at a much lower rate. The rate varies state by state. Therefore, even though the dollars are more of a “sure thing” than Medicare, it is fewer dollars and unless a Long Term Care facility has a high percentage of “private pay patients” (patients who are paying the nursing home bill themselves, frequently in spend down mode), they cannot make it financially on Medicaid patients alone. The term “payer mix” refers to the ratio of patients who are on Medicare, Medicaid and Private Pay.

Many SNF and nursing homes are teetering on the brink of financial disaster if their payer mix is tipped toward the lower paying Medicaid patients. This impacts what they can offer patients in terms of treatment as well as amenities although what is considered an amenity (buildings in good repair, for instance) in a nursing home might be thought of as basic by most of us.

And yet, because the dollars lean towards being a “sure thing”, the tendency to move patients off Medicare, into spend down and subsequently Medicaid is rampant in the industry. And I don’t think it is even done consciously, it is simply done because it works marginally. But guess who is caught in that net? Yes, of course, the patient because had they received their full entitled Medicare benefits instead of the shift to spend down/Medicaid, a high percentage would be discharged home or graduate to a lower level of care. And, as I am going to show you later, restoring patients would save the government lots of dollars.

Please feel free to comment or share your stories of eldercare on my blog. It will take a nation to change things – that means all of us. I will try to be a catalyst, but I can’t do it alone!

Identifying The RIGHT Problem

Elderpride: Chapter 2


Let’s face it; identifying a problem is something we Americans take pride in --especially if it is someone else’s problem. Well then, I need to ask – why are we so horribly deplorable at solving the problems we identify? I don’t think Americans are apathetic, even though we are often accused of it. I think when Americans are under the impression that there is no solution, Americans go on to something else where they think they do have influence or the ability to solve something.

I think there is another component of why problems don’t get solved and that is that we haven’t identified the right problem or there is finger pointing when there should be working together. Identifying the right problem takes a lot of research and study no matter what the issue is. What seems on the surface to be the problem is often a symptom of the problem and solving symptoms leaves us nowhere. Solving symptoms is a Band-Aid™ at best and may even leave the problem in worse condition than before.

Sometimes the problems are so complex that we, the people get discouraged with the amount of research and study long before we know the whole story. This is what has happened in the Long Term Care industry which includes nursing homes, skilled nursing facilities (SNF) and assisted living facilities. Whenever someone thinks they have a solution, invariably they leave out an important piece of the puzzle. In some ways it is worse than a Rubik’s Cube because, any piece of the nursing home puzzle that is left out of the proposed solution mounts a fight against the proposed solution, and so the changes to the system happen in a haphazard and less than fully supported manner.

As we work our way through this maze let’s all keep in mind that we need to identify the right problem(s). It will take more time. I want to take the time to thoroughly examine the things that are ailing this industry while at the same time arriving at solutions that can be brought to the attention of our legislators during the 2008 elections.

I will begin next week by laying the foundation and opening discussion of the payment system for Long Term Care. Please feel free to comment on this blog.

Why Is There A Problem That Needs Fixing?

Elderpride: Chapter 1

We all know there is a problem in America’s nursing homes, we read about it in the newspapers, we hear about it on the evening news, we experience it when we visit an elder member of our family who is a nursing home patient. We might not be able to put our finger on every aspect of the problem but we know it is there – haunting us.

It is complex.

We may have an epiphany when we visit our grandmother, or our father who is a patient in a skilled nursing facility and notice that there are patients calling out and no one answers; or perhaps we take note that patients are lined up in front of the TV, but no one seems to be watching; or it might be that our own family member seems to have “lost it” after one short week in a nursing home. Perhaps we have read about elder abuse in the papers, or heard on the evening news about an elder patient’s spouse who brings a gun to the facility to end the misery.

And we ask for a brief second, “How did we get here?” But then our busy life takes over and we don’t think about it again until the next time we have to visit someone who is in a nursing home. And we hope against all hope that this won’t be us; the more determined of us tell ourselves we will find a way to be taken care of without becoming a nursing home patient. And, for a lot of us, it’s a long way away – years – and things will certainly be changed by then we tell each other.

And we know deep down that it is complex … too complex for us to fix. We have no clue how to get our hands around it and so we continue to turn our heads the other way. Even if we wish we could fix the problems, somehow we know that it is beyond our individual selves and we certainly don’t know where to begin.

Over the next few weeks I am going to attempt to make the complex more simple because I think if more of us could understand the problem, how we got here and what some of the solutions are, then we can work on a solution and do what it takes to fix it so that our mothers, our grandmothers, our fathers and grandfathers won’t have to live in such a situation.

Let’s start with – IT IS NOBODY”S FAULT. It is a systemic problem that has evolved over time. And previous attempts to fix it have failed, perhaps because no one understood what the problem was to begin with. I think at least 75% of being able to solve a problem is identifying what the right problem is. And as simple as that sounds, it has been my experience that more often than not most people don’t identify the right problem when trying to find a solution … to anything!

It would be the easy way out to blame the people who run or work in nursing homes… or the children who don’t pay attention to their elderly parent’s needs… or the physicians who oversee care ...or the government for not paying enough dollars for nursing home care… or our legislators for not listening… or our most intelligent university minds for not arriving at the right solution.

It is both all those things and none of those things! And we can’t have a solution without addressing all of these things. That is one of the things that makes this so very difficult. Creating change that has so many tentacles will not be easy – that is why, it will take a nation.

I invite comments and questions on this blog because it is my mission here to create understanding of a very complex issue – questions and comments will let me know if I am hitting home, or have more “splainin’ to do” – to quote a famous comedian.

Intro to Elderpride

This is my first venture into blogging – it’s just that nothing is being said about the plight of America’s elderly population and how they are treated in their final years – and so I just have to speak up! The purpose of this blog is to dissect a complex issue and garner the interest of the 77 million baby boomers to put their heads together and convince America’s Congress to fix it before we need it! I don’t want to be blogging alone. Please join me with your comments!

I am doing this on behalf of the Dorotha C. White Foundation, a not for profit organization, established for the purpose of creating sweeping change in our nation’s capital that will result in improved quality of life for senior citizens especially the frail elderly who are using skilled nursing facilities and nursing homes either for transitional or residential care.

First and foremost, I realize that it will take a nation to make the kind of changes that will improve life for the elderly. The term Elderpride was coined by the founders of the foundation to indicate what life would be like for an elderly individual if we were able to make the changes that would enable and encourage restorative care in our nation’s Long Term Care industry triggering a movement towards carehouses, and away from warehouses.

Right now, the dirty little secret that everyone hears about and no one talks about is that a high percentage of patients are doomed once they enter a nursing home. Doomed in the sense that they will not recover, they will be routinely diapered even if they are continent, and placed in a wheelchair in front of the TV day in and day out. That is what I am referring to as a warehouse. No one can recover that way. In order to restore a patient’s highest level of functioning that patient needs daily attention to help the patient be able to walk again, eat by themselves, take themselves to the bathroom, take their own shower, dress and groom themselves. That is the description of a carehouse.

For the most part, none of us likes this sad state of affairs – and who among us wants to go to a nursing home? Raise your hand. I don’t see any hands raised! Since we the people don’t know what to do about it, we tend to look the other way thinking it can’t be fixed. And the problem goes on and on. Because who wants to deal with this unpleasantness?

I am here to tell you it can be fixed. It is complex and there are no simple answers – but there are answers. And as a group, we the people need to convince our legislators that we want them to pay attention.

If you are with me so far, it is my goal to add a chapter a week to this blog to inform and educate whoever will listen in a series format. Stay tuned.