Why are rural Westerners killing themselves?
Filed under: Government, Hot Health Headline, Public health
Writing for ABC News, Alan Farnham seeks to explain the jump in suicide rates in the rural American West, particularly in Intermountain states such as Idaho, Wyoming and New Mexico.
Historically the suicide rate in rural states has been higher than in urban ones. According to the most recent national data available, Alaska has the highest rate, at 24.6 suicides per 100,000 people. Next comes Wyoming (23.3), followed by New Mexico (21.1), Montana (21.0) and Nevada (20.2). Idaho ranks 6th, at 16.5. Suicide is the second-leading cause of death for Idahoans aged 15-34. Only accidents rank higher.
Farnham focuses on the Gem State, where suicide rates are rising alongside unemployment and related economic hardship. In addition to economic factors, including cuts to Medicaid funding, and a regional lack of resources for the initial diagnosis of mental illness, local experts point to demographic and cultural factors.
Kim Kane, executive director of Idaho’s Suicide Prevention Action Network in Idaho says other factors explain the high rate of suicide in western mountain states. One is the greater prevalence of guns: In 2010, 63 percent of Idaho suicides involved a firearm, compared with the national average of 50 percent.
She and Garrett also say the West’s pride in rugged individualism can prevent people from seeking help. Their feeling, says Kane, is that they ought to be able to pull themselves up by their mental bootstraps. Idaho is the only state not to have a suicide-prevention hotline.
Americans unprepared to pay for long-term care
Filed under: Aging, Government, Health care reform
In the Chicago Tribune, Deborah Shelton examines how unprepared Americans are to pay for their own long-term care needs as they age. Long-term care tends to slip under the radar because, as one of Shelton’s sources told her, “People buy insurance for their life because they know they are going to die, for their car because they know that can get in an accident and for their health because they know they can get sick, but people don’t tend to buy insurance because they think they are going to need someone to help them take a bath.”
Long-term care encompasses everything from nursing home fees to in-home assistance with everyday routines. It all comes with a price tag; Medicare only covers a limited amount and Medicaid programs apply only to those below certain economic thresholds. That leaves the middle class, who can’t afford the services but don’t really qualify for Medicaid, in the lurch, Shelton writes.
Most people assume Medicare will pay the bills, but the program covers long-term care only under certain conditions and for a limited time. While Medicaid covers long-term care, beneficiaries have to be poor or willing to “spend down” their assets to be eligible. Private insurance can be expensive and excludes applicants with serious medical problems.
As a result, many families pay out of pocket until they exhaust their resources and then turn to Medicaid.
The Affordable Care Act attempted to fill in the blanks, but long-term care provisions of that reform plan withered under intense cost pressure.
An initiative that would have incorporated long-term care into the Obama administration’s health reform plan was scrapped in October after actuaries determined that it would not be financially self-sustainable over the long haul. The Community Living Assistance Services and Supports Act would have created a voluntary, self-funded, employer-based insurance option to help people save for long-term care.
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Long-term care insurance premiums jump
Filed under: Aging, Government, Health care reform, Hot Health Headline, Public health
As the population ages and costs continue rising, paying for long-term care is a big issue for middle class families. Some say long-term care insurance can be a solution, but there are significant issues associated with these products.
In the Minneapolis Star Tribune, Jackie Crosby reports that, “Trapped between fast-rising costs for care and weak returns on their investments, insurers have been raising long-term care premiums by double-digit percentages in Minnesota and nationwide.”
Long-term care coverage has been around since the 1970s, and gained popularity in the ’90s, when the government started offering tax incentives. According to Crosby, it’s getting more expensive now because of what one expert called “the perfect storm.”
Insurers set their rates on assumptions that some people would let their policies lapse. But people held on to policies longer than expected. And their claims are bigger because they’re living longer.
Low interest rates have had perhaps the biggest impact, because insurers planned to cover claims based on reserves they invested. When those investments fell short of expectations, insurers turned to policyholders to make up the difference.
State and federal officials see long-term care insurance as key to limiting the strain placed upon government health programs by America’s aging popular, Crosby writes, and they have thus “spent considerable energy trying to encourage the middle class to plan ahead with long-term care insurance, without much luck.”
The Obama administration last month scrapped the CLASS Act, a long-term care insurance program and major piece of federal health care reform. Minnesota launched a program in 2008 that allows median-income households that buy long-term care policies to shelter some assets if they apply for Medicaid. Still, only about 11 percent of people in the state have the insurance.
Even though the Medicaid program was designed as a safety net for people in poverty, middle-class seniors routinely deplete their assets and turn to the state.
In Minnesota, Medicaid pays about 40 percent of elderly long-term care. Costs could rise fivefold by 2035 to an “unsustainable burden” of $5 billion, according to a report last year from the Citizens League.
Aging in place becoming more popular, possible
Filed under: Aging, Health care reform, Health policy, Hot Health Headline
In the latest installment in The Associated Press series on growing old in America, David Crary explores how the health care system is evolving to accommodate “aging in place” and seniors’ preference to remain in their private homes, even at points when their health care situation might seem to suggest relocation is in order. As the population ages, this preference is starting to play a role in policy decisions.
There’s no question that aging in place has broad appeal. According to an Associated Press-LifeGoesStrong.com poll conducted in October, 52 percent of baby boomers said they were unlikely to move someplace new in retirement. In a 2005 survey by AARP, 89 percent of people age 50 and older said they would prefer to remain in their home indefinitely as they age.
Communities have explored a number of programs to better serve this population, and Crary profiled some of the more notable efforts, including:
- The Naturally Occurring Retirement Community (NORC)
… can be either a specific housing complex or a larger neighborhood in which many of the residents have aged in place over a long period of time and need a range of support services in order to continue living in their homes.
- “Village” organizations
Members of these nonprofit entities can access specialized programs and services, such as transportation to stores, home health care, or help with household chores, as well as a network of social activities with other members.
About 65 village organizations have formed in the U.S. in recent years, offering varying services and charging membership fees that generally range between $500 and $700 a year.
- Aging-friendly homes
AARP has teamed up with the National Association of Home Builders to create a designation for certified aging in place specialists trained in designing and modifying residences for the elderly. Several thousand builders, contractors, remodelers and architects have been certified. Building or remodeling homes can include such details as touchless faucets, trim kitchen drawers instead of cupboards, grab bars and nonslip floors in the bathrooms.
Arizona’s Pima County, along with a few other local governments, has gone a step further, passing an ordinance requiring that all new homes in the unincorporated areas around Tucson offer a basic level of accessibility. They must have at least one entrance with no steps. Minimum heights and widths are set so that light switches can be easily reached and doorways are passable in a wheelchair.
- Medicaid changes
In several states, there’s debate about whether to promote aging in place by shifting more Medicaid dollars to community-based programs and away from traditional nursing facilities. But budget problems may complicate such efforts as some financially struggling states cut back on home health services that help keep some elderly people out of nursing homes.
Medicaid programs slow to act against system exploiters
Filed under: Conflicts of interest, Health data, Hot Health Headline, Public records
At ProPublica, senior reporters Charles Ornstein and Tracy Weber have published the latest turn in their ongoing analysis of conflicts of interest, problem physicians and the disciplinary systems meant to reign them in. This time, they look at Medicaid in Florida and find at least three instances when the state “allowed physicians to keep treating and prescribing drugs to the poor amid clear signs of possible misconduct.”
Their piece revolves around those key examples – two of which were, in all seriousness, brought to their attention by a Scientologist-run watchdog website – and I strongly recommend you read the whole thing for the details. Below, I’ve just highlighted the bigger picture.
In general, Ornstein and Weber found, state Medicaid programs, as well as the federal Centers for Medicare and Medicaid Services, which doesn’t track relevant state data, have failed to act on information which seems to strongly indicate that certain physicians are abusing or exploiting state programs.
Medicaid programs across the country have long had evidence that physicians have been prescribing risky drugs in excess and perhaps to the wrong patients. These prescriptions also racked up huge bills for the programs.
But like Florida, many states did not act on that evidence. Last year, (Sen. Charles) Grassley demanded data from each state about its highest prescribers of pain pills and antipsychotics, and he asked state and federal officials to determine whether the prescriptions written by these doctors were legitimate.
‘Dual eligibles’ pingpong between programs, getting stuck along the way
Filed under: Government, Health care reform, Health policy
The phrase “dual eligibles” has always been a mouthful for describing people old enough (or disabled enough) to be on Medicare and poor enough to be on Medicaid.
M.C. Kim, a cardiac patient quoted in Anna Gorman’s nice Sunday Los Angeles Times piece on the “duals,” comes up with a clear and easy-to-grasp alternative image: pingpong patients.
M.C. Kim had four heart attacks in as many years. Each time, he left the hospital not knowing why his heart had failed.
When he tried to enter a cardiac rehabilitation program to learn how to reduce the odds of having more heart trouble, the Medicare office told him to call Medicaid. The Medicaid office told him to call Medicare. In the end, he said, both denied coverage.
“I was like a pingpong ball,” said Kim, 51, who lives in Los Angeles. “Nobody wanted to take responsibility.”
So Kim kept returning to the emergency room, racking up expensive medical bills for taxpayers.
What questions do you have about health reform and how to cover it?
Joanne Kenen (@JoanneKenen) is AHCJ’s health reform topic leader. She is writing blog posts, tip sheets, articles and gathering resources to help our members cover the complex implementation of health reform. If you have questions or suggestions for future resources on the topic, please send them to joanne@healthjournalism.org.
The “duals” get their doctors and hospitals paid for by Medicare, and their long-term care by Medicaid. (That’s overly simplistic, but you get the main idea.) As they go back and forth between settings, they get caught between two systems that should mesh but often are more like mismatched gears that grind and jam and make noise and get stuck.
Care transitions, a weak point in the health care system in the first place, are particularly disastrous for this population. In fact, the mismatched incentives and insane amount of built-in levers to shift costs may increase the number of care transitions -which boosts costs and create all sorts of opportunities for mishaps and miscommunication that can harm patients.
Gorman’s story is a nice illustration, giving examples from both the elderly and the disabled. She puts a face behind the red tape.
The health reform law takes some steps toward solutions - although this is a tough problem and it’s certainly too soon to say that the reform law will fix it.
A few pieces of a potential solution:
CMS now has a special office on the duals. I interviewed Director Melanie Bella for Kaiser Health News earlier this year. She has testified at least twice before committees in Congress: On June 21 (PDF) she went before the U. S. House Committee on Energy & Commerce, Subcommittee on Health and on Sept. 21 (PDF) she was before the U. S. Senate Committee on Finance. Her testimony can give you an idea of what steps her office is taking and which part is relevant to your state or community.
Medicaid managed care, advanced medical homes, ACOs, penalties for high readmission rates, payment bundling and other reforms may eventually provide better coordinated care for the “duals.” Some of the new programs for the elderly encouraged by the law, such as Independence at Home, may also help. There are more details about delivery system and the duals in this Kaiser Family Foundation brief.
The Alliance for Health Reform also did a whole briefing on this topic a few months ago. This link will take you to resources, an archived webcast, and a transcript (for those of you who would rather skim than watch the webcast)
The SCAN Foundation also has a lot of material on the duals on its website, including this report on state-based solutions.
Groups push for transparency in Joint Commission’s hospital accreditation surveys
Filed under: Health data, Health journalism, Hospitals, Hot Health Headline, Public records, Studies
The Lexington Herald-Leader’s Jim Warren reports that about 50 advocacy groups, including the Consumers Union and Mothers against Medical Error, have joined forces to ask Congress to make the survey data behind hospital accreditation freely available to the public.
Their main target is The Joint Commission, a non-profit group that sets performance standards and is hired by hospitals and other health-care organizations to measure whether they meet those standards. In many states, Joint Commission accreditation is the basis for hospital licensure. It conducts extensive surveys every three years or so, and funds its efforts by charging hospitals upward of $45,000 for the privilege of being evaluated.
The Joint Commission’s disclosure practices last made headlines in January when, in response to pressure from AHCJ’s Right to Know Committee, it made accreditation information more readily available online.
For help finding and understanding Joint Commission reports and similar sources, AHCJ members can check out board president Charles Ornstein’s latest guide to Deciphering Hospital Quality Data, in which he addresses the strengths and weaknesses of myriad data sources and provides pointers on how to access and utilize them.
Fla. system forces ventilator patients to stay in hospitals, incur multimillion-dollar bills
Richard Martin of the St. Petersburg Times reports that, because Florida has few nursing homes that can care for patients on ventilators, some patients are forced to stay in hospitals and rack up enormous bills.
Photo by quinn.anya via Flickr
The patients in question have been stabilized to the point where they no longer need hospital care, though they rely on ventilators, but the hospitals can’t discharge them without finding a facility that can take patients on a ventilator.
Martin reports that fewer than two dozen nursing homes, of about 700 in Florida, care for ventilator patients. Other states pay nursing homes more to care for ventilator patients.
So, in a state where uninsured people go without even basic care, millions of dollars go to ventilator care for people who don’t need to be in hospitals — and who might not even want to be there.
Martin says no one knows how many patients need long-term ventilator care, but one hospital administrator estimates his hospital has three or four patients who fall in this category. According to the Florida Hospital Association, there are about 300 hospitals in the state. The article cites cases in which ventilator patients racked up bills of $9.2 million and $1.7 million.
Hospitals often have no way to collect such bills, and have to write them off as charity care, Martin reports.
Uninsured face delays, increased risks en route to long-term care
Writing for Heart & Soul, Yanick Rice Lamb offers up a comprehensive take on the special challenges patients and hospitals face when it comes to long-term care for the uninsured.
… a growing number of uninsured people … need long-term care after hospital stays. They lack insurance because they can’t afford it, their employers don’t offer it or they were dropped by private carriers after taking out policies on their own. Consequently, these patients experience delays in moving on to the next step in their care once they are medically ready for discharge. They are stuck in the hospital, because it’s hard to place patients in long-term care facilities or send them home with a nurse when they have no coverage, especially when there are complications. Hospitals end up picking up the tab — sometimes even after patients leave. Those costs are ultimately passed on to everyone who pays taxes and anyone who has a medical bill.
Rice Lamb fleshes out this scenario not only with anecdotes, but with a raft of statistics and studies showing that the ranks of such patients are swelling rapidly, as is the financial toll they’re taking on the system. She ties it in with the hospital “frequent flyer” and charity care issues that have received so much ink in recent years. At the same time, she takes a deeper look at the issues faced by the patients themselves, from the difficulty of spending days and weeks away from family, to the lower levels of attention they may receive from hospital staff as their stays drag on, to the increased risk of hospital-acquired infections and lack of specialized rehab.
Some of the most surprising observations came in relation to undocumented immigrants, who present major challenges despite being a small part of the patient population.
In some cases, when community support can’t be found, Rice Lamb writes that hospitals “Often pay to transport immigrants back to their countries — if the patients agree — and sometimes cover medical bills in their homelands. This often costs less than absorbing the expense of continuous care in the United States.”
Furthermore, she says, “Even with U.S. citizenship, language barriers can contribute to discharge delays. When caregivers spoke little English, the length of stay increased to 6.1 days, compared to four days for the control group, according to a study published recently in the Archives of Pediatrics & Adolescent Medicine.”
Throughout her work, Rice Lamb takes advantage of sources which reporters around the country should find useful when localizing similar topics.
Rice Lamb completed this project while on an AHCJ Media Fellowship on Health Performance, supported by the Commonwealth Fund.
Kenen suggests topics for regional, local Medicaid stories
My last blog post was on coverage of Medicaid, and we’ve just posted a tip sheet about it, pointing out that if you think the story is going in several incompatible directions simultaneously (expand, contract, blow up, salvage, reform) you are right. As it’s an undercovered but extremely important topic, I thought I’d stick with it for this post too.
What questions do you have about health reform and how to cover it?
Joanne Kenen is AHCJ’s health reform topic leader. She is writing blog posts, tip sheets, articles and gathering resources to help our members cover the complex implementation of health reform. If you have questions or suggestions for future resources on the topic, please send them to joanne@healthjournalism.org.
Looking at coverage nationally, I’m still finding a lot of legislative process stories, or bits and pieces stories. I’m still on the lookout for good regional and local stories on Medicaid – I’d love to see some good ones about delivery system reform in Medicaid and, for those of you in states with Republican governors endorsing block grants, some tough questions about exactly what the state would do with all that flexibility and not all that much money. In the meantime, here are a few stories that I think shed some light on current Medicaid issues.
There were a couple of pieces about the Rhode Island “global waiver,” which has become the equivalent of a poster child for the block grants favored by Republicans – even though the savings may be far more modest than touted and the state was getting MORE money than it would have without the waiver, not less as it would under block grants. (I wish the latter point had been made higher up in Phil Marcelo’s very good story.)
• Janet Roberts, on May 15 in The New York Times: Rhode Island’s Medicaid Experiment Becomes a Talking Point for Budget Cutters
• Philip Marcelo, on May 16 in The (R.I.) Providence Journal: R.I. Medicaid agreement admired in other states
• A few earlier stories tracking developments in Rhode Island include Felice Freyer’s April 11 story in The (R.I.) Providence Journal, State looking to maintain Medicaid coverage level, and, for a focused look at how hard it is to define and compare Medicaid savings even in neighboring states, see Confusion over Medicaid numbers in The (R.I.) Providence Journal by Randal Edgar and Philip Marcelo.
• In Fla. Pilot program to cut Medicaid costs raises new questions, N.C. Aizenman in The Washington Post on May 11 looks at whether 1)the cost savings are real 2)whether quality of care is being damaged.
• Phil Galewitz at Kaiser Health News writes about Florida’s proposal to charge poor people on Medicaid monthly premiums and $100 for nonurgent ER visits (some advocates point out that it could be a dangerous deterrent for people who may have symptoms like chest pains that could be a true emergency or could turn out to be less serious)
• This May 2 story – just a short really but packs in some good information in a small space – by Carrie Ghose of Columbia Business First, Feds mull ‘mystery shoppers’ to gauge Medicaid access to doctors.
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