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  1. Medicare Enrollment Problems Persist
  2. Medicare’s New Skilled Nursing Facility Payment System Alters Access to Care
  3. Poorly Performing Skilled Nursing Facilities: What Happens to Them?
  4. Latest Edition – Elder Justice: What “No Harm” Really Means for Residents 

Medicare Enrollment Problems Persist

Problems with Medicare Plan Finder Persist

As reported by SHIPs across the country and some of our partner organizations, problems with the new Medicare Plan Finder (MPF) persist during the current Medicare Annual Election Period, which lasts through December 7, 2019. These problems include: inaccurate information about covered drugs and costs, non-formulary drugs, dosage options, copays for individuals with the Part D Low Income Subsidy (LIS) and problems creating a MyMedicare account.

We are aware that one Part D plan sponsor, EnvisionRx, in an email to agents and brokers dated October 31st instructed those agents and brokers to no longer use MPF until certain problems are fixed:

We want to make you aware of several issues with the new release of Medicare Plan Finder. The issues are affecting drug pricing for all plans. Drug pricing is not calculating correctly for carriers with plan designs that have a deductible that applies for specific tiers only. Also, mail order pricing is still only pricing for Standard and not Preferred mail order pharmacies. Until these matters are resolved, we encourage you and your clients to use [the plan’s website] to check drug pricing.

We are also aware that CMS is working to resolve these functional issues, and is providing regular updates to the SHIP network. But these fixes are ongoing, in the middle of an enrollment period, and people are making enrollment decisions based upon inaccurate information.

While those enrolled in MA plans have an additional opportunity to change plans between January and March through the Medicare Advantage Open Enrollment Period, those enrolled in stand-alone PDPs do not have such options. Further, problems might not arise or be identified until later in the year.

As stated in our August 2019 joint letter with Medicare Rights Center, Justice in Aging and National Council on Aging raising concerns about the MPF and marketing guideline changes, CMS must “provide any enrollment relief that may be needed to prevent beneficiaries from being negatively impacted.” It is becoming more evident that such action is required.

Medicare Messaging: All about “Plans,” Not Traditional Medicare

As outlined in previous Alerts, the Center remains concerned about CMS efforts to steer individuals toward Medicare Advantage (MA) plans rather than adhere to its role as a neutral source of information about coverage options. While promoting the Medicare Plan Finder – notwithstanding the problems discussed above – CMS should make clear that people with traditional Medicare can stay put if they wish, and people enrolled in MA can consider the option of returning to traditional Medicare. Instead, information coming from CMS focuses almost exclusively on “plans” and “plan choices” with little or no reference to traditional Medicare as an option.

For example, a recent email from CMS (dated Oct 24) focuses only on “plans.”  The email opens:

“Happy with your current 2019 Medicare coverage? Plans — and your health care needs — may change from year to year, so it’s still important to take a few minutes and shop around during Medicare Open Enrollment.”

After touting the new MPF, the email concludes:

“If you’re happy with the coverage you have now, and your plan is still being offered next year, you don’t need to do anything further. But if you find a plan that better meets your needs for 2020, you can easily enroll online until December 7.”

Similarly, a November 7th email from Medicare makes no mention of traditional Medicare as an option:

“Medicare Open Enrollment is your chance to compare 2020 plans and choose what’s best for you.”

The email links to a video about the new MPF that includes the narrator statement:

“It’s easier than ever to learn the key differences between Original Medicare and Medicare Advantage before shopping for health and drug plans.”

MPF Information Comparing Traditional Medicare and MA is Incomplete

On the new Plan Finder landing page, under the statement “New to Medicare?” there is a tab labelled “Learn more about options” that allows individuals to see some basic comparisons between the traditional Medicare and MA. This information, though, is incomplete. As noted by the National Association of Insurance Commissioners (NAIC) in an October 16, 2019 letter to CMS, concerns about the MPF include the fact that:

“The cost comparison between Medicare Advantage (MA) and Medicare with a Medigap plan does not capture out of pocket costs – only premiums. This gives the false sense that Medigap is much more expensive overall than an MA plan.”

This echoes concerns the Center for Medicare Advocacy has previously raised about other coverage compare tools on the Medicare website.

Need for Balanced Information

A prominent MA insurance industry-backed organization, which promotes itself as a beneficiary advocacy group, recently sent materials to Congressional members’ offices promoting enrollment in Medicare Advantage during the current enrollment period, calling their guidance “an educational tool to help legislative offices engage and inform Medicare beneficiaries on the choices they have in Medicare.” In the document, they provided charts and other information “adapted” from the 2020 Medicare & You handbook, but did so in a way that paints Medicare Advantage in a light most favorable, reworking such material so that any disadvantages of MA plans are downplayed.

Promotion of MA plans by the MA industry is to be expected (as long as actors are clearly identified as working on the industry’s behalf).

Promotion of MA plans by the Medicare program itself, however, is a breach of trust.

As noted in earlier Alerts, in an attempt to provide more balanced information about the choices between traditional Medicare and MA, the Center along with the National Committee to Preserve Social Security and Medicare relaunched our Fully Informed materials.

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Medicare’s New Skilled Nursing Facility Payment System Alters Access to Care

Medicare’s new reimbursement system for skilled nursing facilities (SNFs), called Patient-Driven Payment Model (PDPM),[1] changed reimbursement rules and the financial incentives for SNFs, effective October 1, 2019. Just one month since implementation, some of the problems that were predicted as a result of PDPM[2] are already being seen.

The former reimbursement system, Resource Utilization Groups (RUGs), largely paid facilities higher rates, the more therapy they billed for. PDPM, on the other hand, pays more if SNFs provide no therapy at all. Public reports on October 1 indicated, and therapy associations report, that thousands of therapists lost their jobs, or had their hours reduced, across the country.

Due to new payment incentives, it is also now clear that SNFs are changing their admissions practices. Facilities that previously denied admissions to people who use ventilators are now actively recruiting ventilator-dependent residents. Unfortunately, the Center has heard two recent stories that indicate that the facilities recruiting people with ventilators are among the poorest quality facilities in the country. A one-star facility that is on the “candidate” list for the Special Focus Facility program announced, through a press release, that it was now providing ventilator care. In another state, a local ombudsman reported that residents at a poor quality SNF told her they were being moved to another floor to make room for ventilators.

A rush of poor quality SNFs to admit people with ventilators is especially troubling. The New York Times reported in September that drug-resistant infections are prevalent, and deadly, for residents in nursing facilities who use ventilators because of insufficient nursing staff and poor infection control practices.[3] The Centers for Medicare & Medicaid Services reports that, each year, infections in nursing facilities are responsible for 150,000 hospitalizations, 388,000 resident deaths, and health care costs between $673 million and $2 billion.[4]

The Center for Medicare Advocacy wants to hear from anyone with information about ventilator patients and care in nursing homes.

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[1] 83 Fed. Reg. 39162 39183-39265 (Aug. 8, 2018).
[2] See “Potential Impacts of New Medicare Payment Models On Skilled Nursing Facility and Home Health Care” (CMA Alert, Oct. 31, 2019), https://www.medicareadvocacy.org/potential-impacts-of-new-medicare-payment-models-on-skilled-nursing-facility-and-home-health-care/.
[3] “Matt Richtel, Andrew Jacobs, “Nursing Homes Are a Breeding Ground for a Fatal Fungus,” (Sep. 11, 2019), https://www.nytimes.com/2019/09/11/health/nursing-homes-fungus.html?searchResultPosition=1.
[4] 81 Fed. Reg. 68688, 68808 (Oct. 4, 2016) (Final rule), 84 Fed. Reg. 34737, 34746 (Jul. 18, 2019) (Proposed rule) (omitting hospitalization data).

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Poorly Performing Skilled Nursing Facilities: What Happens to Them?

The Centers for Medicare & Medicaid Services (CMS) identifies 88 nursing facilities nationwide that are among the most poorly performing facilities in the country. CMS calls these facilities, generally two per state, Special Focus Facilities (SFFs). SFFs have a special icon on the federal website Nursing Home Compare that identifies their SFF status. At present, CMS does not report any quality ratings for these facilities. CMS also identifies, monthly, an additional 400+ facilities that meet the Special Focus criteria status – the “candidate list.”

 

The Center for Medicare Advocacy looked at the 21 nursing facilities that CMS reported in May 2019 had “graduated” from the SFF Program.[1] We found that, in the year before they “graduated,” six of the 21 SFFs were cited with one or more harm or immediate jeopardy deficiencies, the two highest categories of noncompliance in the federal regulatory system that are applied to less than 5% of all deficiencies.

On October 31, 2019, the Center again looked at the May 2019 graduates in order to determine how they were rated on Nursing Home Compare five months after they graduated. The most troubling finding was that 5 of the 19 we could find on Nursing Home Compare – more than a quarter – were on the October 23, 2019 candidate list of SFFs. In other words, they had rejoined the ranks of the worst-performing facilities in the country. Moreover, the recent graduates continued to rate poorly on the CMS website, particularly in their ratings for health inspections and overall ratings. The graduates performed “best” only on the largely self-reported quality measure domain, once again underscoring how meaningless this quality measure domain is.

Star Ratings of the 19 May 2019 Graduates from SFF Program, as of October 31, 2019

Star ratings Overall rating Health survey rating Staffing rating Quality domain rating
1 star 7 facilities 10 facilities  4 facilities (including 2 w/icon) 0
2 stars 8 facilities   7 facilities 10 facilities 5 facilities
3 stars 3 facilities   1 facility  4 facilities 5 facilities
4 stars 0   0  1 facility 5 facilities
5 stars 1 facility   1 facility 0 4 facilities

Fifteen of the 19 graduates had overall ratings of “much below average” (one star) or “below average” (two stars).

The 19 graduates performed most poorly on their health survey ratings; 17 were rated “much below average” (one star) or “below average” (two stars). Two of these facilities boosted their overall rating by one star because of their five-star rating on the quality measure domain.

Conclusion and Recommendations

The SFF program is not achieving its goal of addressing the worst-performing nursing facilities and bringing them into sustained compliance with Requirements of Participation. We reiterate, and strengthen, our recommendations from June 2019 on ways to revise graduation policies so that a facility is not removed from SFF status until the following have been achieved:

  • The facility has not been cited with a harm-level or immediate jeopardy deficiency for 18 months;
  • The facility has not been cited with four or more no-harm deficiencies for 18 months;
  • The facility has not had an abuse icon for 18 months;
  • The facility has not had more than two complaint surveys conducted for 18 months; and
  • The facility has staffing levels of at least four stars for 18 months.

As we noted in June, facilities that have been selected for the SFF program because of a multi-year history of providing extremely poor care should not graduate until they have fully returned to compliance and demonstrated their sustained compliance for 18 months.  To allow facilities to graduate when they were recently cited with significant deficiencies, had multiple complaint surveys, or had inadequate staffing levels invites the recidivism that The New York Times documented in July 2017.[2]

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[1] CMA, “Special Report – “Graduates From the Special Focus Facility Program Provider Poor Care” (Jun. 20, 2019), https://www.medicareadvocacy.org/graduates-from-the-special-focus-facility-program-provided-poor-care/.
[2] Jordan Rau, “Poor Patient Care at Many Nursing Homes Despite Stricter Oversight,” The New York Times (Jul. 5, 2017), https://www.nytimes.com/2017/07/05/health/failing-nursing-homes-oversight.html?searchResultPosition=1.

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Latest Edition – Elder Justice: What “No Harm” Really Means for Residents

Elder Justice: What “No Harm” Really Means for Residents is a newsletter published by the Center for Medicare Advocacy and the Long Term Care Community Coalition. The purpose of the newsletter is to provide residents, families, friends, and advocates information on what exactly a “no harm” deficiency is and what it means for nursing home residents. Our latest issue has real stories from nursing homes in New York, Pennsylvania, Iowa, and Oregon.

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