Archives for August 2017

Safety Is Key When Working With Elders

Financial and emotional abuse are the most common forms of elder abuse facing this population today.  In a 2011 report of New York State elder abuse, only 1 in 24 cases of elder abuse were reported to authorities. When working with elders, caregivers, or families during a transition — aging in place, right-sizing, downsizing, or moving & transitioning, our T3 team members often are frontline in identifying cases of elder abuse.  For some elders, a visit to the emergency room is frontline primarily because it may be the only time they leave their home.

The following story recently was published by Kaiser Health News* about an innovative program for protecting elders through intervention in there ER.  We are very proud to say that our team members are trained to identify elder abuse when present.

Abuse often leads to depression and medical problems in older patients — even death within a year of an abusive incident.

Yet, those subjected to emotional, physical or financial abuse too often remain silent. Identifying victims and intervening poses challenges for doctors and nurses.

Because visits to the emergency room may be the only time an older adult leaves the house, staff in the ER can be a first line of defense, said Tony Rosen, founder and lead investigator of the Vulnerable Elder Protection Team (VEPT), a program launched in April at the New York-Presbyterian Hospital/Weill Cornell Medical Center ER.

The most common kinds of elder abuse are emotional and financial, Rosen said, and usually when one form of abuse exists, so do others. According to a New York study, as few as 1 in 24 cases of abuse against residents age 60 and older were reported to authorities.

The VEPT program — initially funded by a small grant from The John A. Hartford Foundation (a Kaiser Health News funder) and now fully funded by the Fan Fox and Leslie R. Samuels Foundation — includes Presbyterian Hospital emergency physicians Tony Rosen, Mary Mulcare and Michael Stern. These three doctors and two social workers take turns being on call to respond to signs of elder abuse. Also available when needed are psychiatrists, legal and ethical advisers, radiologists, geriatricians and security and patient-services personnel.

“We work at making awareness of elder abuse part of the culture in our emergency room by training the entire staff in how to recognize it,” said Rosen. It’s easy for the ER staff to alert the VEPT team and begin an investigation, he said.

A doctor interviews the patient and conducts a head-to-toe physical exam looking for bruises, lacerations, abrasions, areas of pain and tenderness. Additional testing is ordered if the doctor suspects abuse.

“Unlike with child abuse victims, where there is a standard protocol in place for screening, there is no equivalent for the elderly, but we have designed and are evaluating one,” said Rosen.

The team looks for specific injuries. For example, radiographic images show old and new fractures, which suggest a pattern of multiple traumatic events. Specific types of fractures may indicate abuse, such as midshaft fractures in the ulna, a forearm bone that can break when an older adult holds his arm in front of his face to protect himself.

When signs of abuse are found but the elder is not interested in cooperating with finding a safe place or getting help, a psychiatrist is asked to determine if that elder has decision-making capacity. The team offers resources but can do little more if the patient isn’t interested. They would have to allow the patient to return to the potentially unsafe situation.

Patients who are in immediate danger and want help or are found not to have capacity may be admitted to the hospital and placed in the care of a geriatrician until a solution can be found. Unlike with children and Child Protective Services, Adult Protective Services won’t become involved until a patient has been discharged, so hospitalization can play an important role in keeping older adults safe.

During the first three months of the program, more than 35 elders showed signs of abuse, and a large percentage of them were later confirmed to be victims. Changes in housing or living situations were made for several of them.

“It’s difficult to identify and measure appropriate outcomes for elder abuse victims, because each patient may have different care goals,” said Rosen, “but we are working on making a case that detection of elder abuse and intervention in the ER will improve the patients’ lives. We also hope to show that it will save money, because when an elder is in a safe place, expensive, frequent trips to the ER may no longer be needed.

The team’s ultimate goal is to optimize acute care for these vulnerable victims and ensure their safety. They plan to work at continually tweaking VEPT to improve the program and to connect to emergency medical, law enforcement and criminal justice services. Eventually, they hope to help other emergency departments set up similar programs.

* Kaiser Health News, a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation.




Big Changes to Medicare Plan Finder by CMS

Understanding Medicare can be a full time job.  Medicare Advantage and part D plans can be hard to understand – or compare during open enrollment.  As a reminder, Medicare Part D is the Medicare prescription drug benefit that subsidizes the cost of prescription drugs and prescription drug insurance premiums.  Medicare Advantage plans typically offer additional coverage — vision, hearing, dental, health & wellness.

The following is an excerpt from Medicare Advantage News discussing changes to the medicare Plan Finder.  Changes will enhance the benefit data display that increase transparency and go live 1 October 2017.

CMS unveiled the planned changes in a May 22 memorandum sent to all Medicare Advantage and Part D plan sponsors, saying the enhanced “benefit package data display” will go live on Oct. 1, 2017.

While CMS did not respond to a request from AIS Health for additional commentary on why it is making these specific changes, a top agency official speaking at last month’s Medicare Advantage and Prescription Drug Plan Spring Conference identified enhancing the beneficiary plan selection process as a chief goal of CMS this year. “Our focus is to improve the visibility of the beneficiaries in the Medicare program to identify the best options for them,” stated Demetrios Kouzoukas, principal deputy administrator and director with the Center for Medicare.

According to the memo, the planned MPF enhancements include, but are not limited to:

  • More benefit categories, including preventive care, diagnostic procedures/lab services/imaging, hearing services, preventive and comprehensive dental services, vision services, rehabilitation services, transportation, foot care (podiatry services), wellness programs and Medicare Part B drugs;
  • In-network vs. out-of-network cost share information;
  • Authorization and referral information;
  • Optional supplemental benefits with monthly premium and deductible; and
  • An expanded display for drug costs and coverage.

“If CMS chooses to list of all of these benefits in a co-equal way, it is a big change,” says Michael Adelberg, principal with FaegreBD Consulting and a former top CMS MA official. “Historically, CMS has sought to focus decision-making on a smaller number of core benefits.”

CMS has also historically favored minor adjustments over broad-scale changes, most recently making a series of tweaks highlighting which plans are under an enrollment sanction and adding more information about the sanction itself (MAN 9/15/16, p. 1).

But adding so much new information could be problematic, consumer advocates advise. “The Medicare Plan Finder has always been an extremely important resource for Medicare beneficiaries seeking unbiased information about Medicare health plans,” remarks Jane Sung, senior strategic policy advisory with the AARP Public Policy Institute. “While AARP is pleased to hear that CMS is continuing to improve the Medicare Plan Finder, we remain concerned by the growing breadth and complexity of the information that is being presented. AARP has long argued that the Medicare Plan Finder should be more user-friendly so that it can better assist Medicare beneficiaries as they analyze their plan options.

She continues, “While the new information is certainly relevant given constantly evolving Medicare Advantage and Medicare Part D plans, CMS should ensure that it is presented in a manner that is useful and easily understandable for beneficiaries and their families.”

Consumer Advocates Question Usability

The Medicare Rights Center, which offers a national help line to assist Medicare beneficiaries in navigating the MPF during the Annual Election Period, is cautiously optimistic about the planned changes. “Those are all really good goals and we’re excited to see what CMS does, but I think we’ll have to wait and see a little bit in terms of how usable that information is in the Plan Finder tool. But those are things we think are important to include,” Casey Schwarz, senior counsel for education and federal policy, remarks of the planned enhancements.

Medicare Rights last year issued a series of recommendations to CMS on enhancing the MPF, including providing more “individually tailored information on the summary/comparison results page,” and requested that the tool make it easier for beneficiaries to see if their providers are in selected plans’ networks rather than being redirected to a plan’s website and having to start from scratch. A “searchable provider directory” for each MA plan on the plan finder would streamline the selection process, suggested the nonprofit organization.

Neither a searchable provider directory nor an option for individually tailored information were included in the list of planned changes issued by CMS. “We’re going to continue to push CMS for providing more information that is relevant to a particular person based on any of their claims data or information that they enter into the Plan Finder tool, such as information about the doctors that they use and whether the network includes their doctors,” says Schwarz. But based on CMS’s response to the September 2016 letter from Medicare Rights and other conversations, there are technological and other limitations facing CMS that may keep it from establishing, for example, a searchable provider directory.

Nevertheless, Medicare Rights has observed that CMS is “willing to make improvements” to the tool and that prior changes, such as increased accuracy and more frequent updating to address problems experienced during open enrollment, have made it more usable over time, adds Schwarz.Meanwhile, whether the expansion of core benefits on display will drive plans to incorporate more low cost “extras” (e.g., dental and vision benefits, wellness programs) into their bids remains to be seen. Shelly Brandel and Pat Dunks, both principals and consulting actuaries with Milliman, say there was no immediate reaction from plans to change up their 2018 bids (see story, p. 1). But the revisions may have more of an impact next year, if there appears to be a trend of seniors gravitating toward plans that include more of those benefits in their plan benefit packages, they suggest.