High Profile Report – Faulty Medicare Rating System?

Nursing homes and long-term care facilities are among the many health care providers that can submit reimbursements to Medicare and Medicaid, which are federal programs administered through the states, for expenses incurred for treating and caring for patients who are insured by Medicare or Medicaid. These federal program s lay out certain rules that providers must follow in order to maintain eligibility for such reimbursements.

The government also provides reviews and ratings on certain facilities, including disciplinary action taken against them for violating rules. The Centers for Medicare and Medicaid Services (CMS) specifically uses what it calls a “Five-Star Quality Rating System” for its Medicare program to provide information to consumers, including patients and/or their families and caregivers, in doing the due diligence to find the right facility for the best level of care. As the New York Times describes it, it is like a hotel-style rating. Approximately one fifth of the over 15,000 nursing homes across the United States has the top 5-star rating.

Nursing Home Settles False Claims Act Case

The False Claims Act is a law that allows for the government to sue those who have allegedly defrauded the federal government. These lawsuits can also be filed by individual citizens who believe they have uncovered evidence of fraud against the federal government, and the United States Department of Justice has the option to get involved and prosecute the matter.

Medicare & Medicaid Fraud in Nursing Homes

In the healthcare industry, there are often many examples of fraud in the context of Medicare and Medicaid. Medicare and Medicaid are of course programs administered by both federal and state governments, largely with federal dollars. In exchange for accepting money for either program, states and healthcare providers must follow certain rules and regulations as to how they conduct themselves and do business. If all goes well, those providers can then submit for reimbursement from Medicare and Medicaid. However, many providers unfortunately will overbill these programs in order to get back more money, which is pure and simple a fraud perpetrated on the government. Many states have their own versions of the False Claims Act, and can also be the target of fraudulent activity.

Speaking Up – Whistleblowers Help Avert Healthcare Fraud

Whistleblowers have played a vital role in weeding out illegal practices in the private sector, abuse of authority, waste, fraud and gross mismanagement in government agencies, and improper activities in international institutions. As we have seen time and time again, whistleblowers have also played a vital role in the healthcare sector, be it in the private sector or the government.

Reporting Illegal and Unethical Conduct

Whistleblowers helped bring to light the scandal at the Veterans Administration, where it was discovered that multiple hospitals and care facilities run by the VA across the country kept patients waiting for visits and treatment for months at a time. Such neglect hastened their illnesses and injuries, and led to untimely deaths for many. To make things worse, the VA furthermore covered up these horrible issues. Whistleblowers have also been valuable in ferreting out fraud when it comes to Medicare and Medicaid programs. Where an individual blows the whistle on fraud under the False Claims Act, he or she can reap a bounty payment for their efforts if the government recovers. This also depends on other circumstances, such as the size of the recovery. As with any false claims case, such false claims stand to defraud the government as well as the taxpayers.

Medicare Star Ratings and Quality of Care

Five-Star Nursing Homes May Not the Best Indicator of Care

Are Medicare star ratings good predictors for the quality of care at nursing homes?  According to a recent article in the New York Times, a facility with a five-star rating may not be what one would expect.  In fact, many five-star facilities have receiIMG_29490008ved fines for injuries related to nursing home neglect.

Rosewood Post-Acute Rehab, a nursing home located in a Sacramento suburb, received a five-star rating from Medicare.  The nursing home “bears all the touches of a luxury hotel, including high ceilings, leather club chairs, and paintings of bucolic landscapes.”  According to the article, getting a five-star rating—the highest possible—is not easy.  Only about one-fifth of all nursing home in the U.S., about 3,000 total, hold this distinction.

Yet the star rating can be misleading to consumers.  Based on research conducted by the New York Times, a Medicare “seal of approval” is often based on incomplete information about the living conditions at these nursing homes.  The star ratings “are based in large part on self-reported data by the nursing homes that the government does not verify.”  Three criteria are used to determine Medicare star ratings, including:

  •      Staff levels;
  •      Quality statistics;
  •      Results of annual health inspections.

Only the third criterion—the results of annual health inspections—receives verification by independent reviewers.  The staff levels and quality statistics are based on data reported by the nursing homes themselves and taken at face value, “with limited exceptions.”

Negative Information Not Included in Star Ratings

It is problematic that the Medicare star ratings, known as “gold standards” in the industry, receive much of their information from nursing homes’ self-reporting.  Even more problematic, perhaps, is that the ratings do not “take into account entire sets of potentially negative information.”  What type of negative information gets ignored?  Generally, it is information about fines and enforcement actions taken by state authorities, or consumer complaints filed with state, rather than federal, agencies.

How does this play out in practice?  In the case of Rosewood, the State of California fined Rosewood $100,000 last year for “causing the 2006 death of a woman who was given an overdose of a powerful blood thinner.”  The penalty is the highest levied in California.

Rosewood did not only receive one fine, either.  Between 2009 and 2013, state agencies received hundreds of consumer complaints about Rosewood.  The State of California estimates it received 102 complaints, while the advocacy group California Advocates for Nursing Home Reform (CANHR) indicates that 164 consumers filed complaints against Rosewood.  If those numbers are correct, Rosewood received twice the number of complaints as the state average.

If your elderly loved one suffered an injury resulting from nursing home abuse or neglect, contact an experienced San Diego nursing home abuse lawyer today.

Photo Credit: psarahtonen via morgueFile

See Related Blog Posts:

Assisted Living Reforms Are Not Enough, Some Advocates Say

MRSA Infections Detected in Southern California Nursing Homes

Keeping a Close Eye – The Need to Monitor Breathing Tubes

Some elderly and incapacitated resident patients of nursing homes and long-term care facilities have to use breathing tubes in order to aid their breathing and the oxygenation of their bodies and brains. Without the proper level of oxygen going to the brain, a person can suffer brain damage and eventually death. Unfortunately, in some sad instances a patient’s breathing tube can become clogged, and the effect is essentially like choking, where the person’s oxygen is depleted and they can lose consciousness, suffer brain damage, and die. If they are saved in time, brain damage could affect them for the rest of their life.

Breathing tubes are used to aid those who are unable to breathe on their own. These tubes in general are plastic tubes inserted into a patient’s throat or nose. Where a breathing tube is needed for a longer term of time, a more involved setup will be used where the tube extends down the patient’s throat, and makes it impossible for them to eat, drink or speak so that they need nutrition and water either intravenously or through a separate feeding tube.

Back to the Basics – Falls in Nursing Homes

Falls can happen anywhere and anytime to anyone. Yet the common stories we hear most about tend to be when our elderly or otherwise incapacitated loved ones suffer a fall, largely because of any incapacity. Such falls can lead to serious injuries, such as broken or fractured bones, concussions, and even death. There is also an enormous psychological impact, as one fall can leave a person in perpetual fear of falling again, which can in turn lead to self-isolation and even depressive thoughts of helplessness.

In nursing homes, falls are a significant problem, and lead to even bigger problems. According to the Centers for Disease Control (CDC), as of 2012, for every 100 nursing home beds, there are approximately 100 to 200 falls per year, including some who fall more than once. And among the multitude of falls that occur, almost 2,000 people die each year from a fall at a nursing home, and anywhere from 10%-20% of falls at nursing homes can cause serious injuries, while 2%-6% result in bone fractures. Interestingly, 35% of falls occur with nursing home residents who are unable to walk, which may call into question the lack of supervision of those people by nursing home staff. According to the CDC, some of the many causes of falls in nursing homes include:

Assisted Living Reforms Are Not Enough, Some Advocates Say

Many of us have heard about assisted living facility reforms pending before the California legislature, as well as those aimed specifically at residential care facilities for the elderly (RCFEs).  But are those reforms sufficient to ensure that California seniors are safe from elder abuse?  According to a recent story from KQED’s State of Health, many elder justice advocates in California do not believe the reforms are going to do enough.

Recent History of Elder Abuse in San Diego

According to Deborah Schoch, an advocate with the California HealthCare Foundation Center for Health Reporting, the number of assisting living facilities in our state essentially doubled over the last 25 years.  For whom are these faciwoman-65675_1280lities designed?  According to Schoch, they are intended for older, healthy adults who are “relatively independent.” Yet many of these facilities have taken in patients who require much more extensive levels of care, and assisted living facilities “are not designed to deliver skilled nursing care.”

Schoch recently helped report on numerous deaths resulting from elder abuse or neglect in San Diego County assisted living facilities.  Her work led the San Diego district attorney’s office to create a “special unit” designed to “target crime in the facilities.”  However, such a unit is not sufficient to combat the rampant nursing home abuse taking place in facilities across the state.  As a result, a number of lawmakers are proposing new legislation aimed at ensuring our seniors receive the care they need.  But will the new legislation be sufficient?

Lawmakers Seek to Change Elder Care

Across the state, lawmakers have listened to testimony from reform advocates concerning the state of elder abuse in assisted living facilities.  In Sacramento, lawmakers heard from Aaron Byzak, an advocate who founded “Hazel’s Army” following his grandmother’s preventable death in an assisted living facility.  When his grandmother died as a result of the facility’s neglect, the state only issued a $150 fine.  In Sacramento, according to the KQED story, fines and regulations “haven’t changed much in close to 30 years.”

How have lawmakers reacted?  Pat Leary, Chief Deputy Director of the California Department of Social Services, emphasizes the need “for a revamp.”  She referred to a number of bills pending before the legislature that would include some of the following reforms:

  •      Raising the maximum fine from $150 to $15,000;
  •      Upgrading the online “violations” database to make it more accessible to the public;
  •      Creating a medical expertise unit;
  •      Establishing a corporate accountability unit.

Leary explained that the state’s current inability to track elder abuse trends has been a serious problem, as The California Department of Social Services only “tracks facilities on a one-facility-at-a-time basis.”  However, a corporate accountability unit could change that.

Advocates “say they’re heartened” by the proposed legislation, but they “worry about the fine print.”  For instance, Chris Murphy and Christina Selder, two ardent advocates from the San Diego area, sponsored a bill requiring assisted living facilities to carry liability insurance.  That bill passed, and has since been signed into law. However, Murphy explained that, if certain features are not “clearly stipulated within the bill, then it’s left to the regulators, then the regulators are going to come up with whatever they come up with.”

According to KQED, Selder “worries lawmakers are tweaking a system that is fundamentally dysfunctional.”  Perhaps, she explained, lawmakers should be looking to give the system a complete overhaul, rather than designing laws that act more like analgesics.

Contact a San Diego Elder Abuse Lawyer

Do you have an elderly loved one in a nursing home or assisted living facility in Southern California?  It is often difficult to know for certain whether an older adult is receiving proper care.  If you suspect that your parent has sustained injuries because of nursing home abuse or neglect, it is important to talk to an experienced San Diego nursing home abuse lawyer.

Photo Credit: geralt via pixabay

See Related Blog Posts

California Needs a Tech Upgrade: Online Information and Assisted Living Facilities

Financial Elder Abuse Continues to Thrive in California

Psychiatrist Suspended and Sued for Dangerous Use of Medications

One of the major issues we recently wrote about in the context of nursing homes and elder care has been the use of chemical restraints on residents. A problem has been the misuse and overuse of these medications, as well as the oscillating back and forth between different types of medications, including ones that were never even prescribed.

In a recent case, a psychiatrist’s license has been suspended indefinitely by the Illinois Medical Board for his prescribing a certain antipsychotic medication to his patients. Dr. Michael J. Reinstein used the antipsychotic drug called clozapine on what the Chicago Tribune reports as more than 50% of his patients at nursing homes and mental health facilities. This drug is “known as a risky drug of last resort,” and was associated with the deaths of three patients under Reinstein’s case. The drug has also reportedly been at the center of shady kickback deals between the drug’s maker and doctors, and Dr. Reinstein’s case is no different. Dr. Reinstein has been accused of using the drug in exchange for $350,000 in bribes from the drug’s manufacturer, Teva Pharmaceuticals, over the course of seven years, in spite of the fact that he could employ other medications or treatment methods for his patients, and in spite of the danger the drug poses to the health, well-being, and ultimately lives of patients. Reinstein also allegedly received other gifts from the company, including free travel, a fishing trip, boat cruise, and dinners, as well as sporting event tickets. This indefinite license suspension by the medical board was the culmination of a years-long investigation by the Chicago Tribune and ProPublica.

Illinois Statute Aims to Decrease Elder Abuse

The state of Illinois takes elder abuse very seriously. This is evident from the state legislation that defines the problem and mandates the response of specific agents within the jurisdiction. The Elder Abuse and Neglect Act was implemented in 1988 based on concerns for the safety of older residents. The initiative defines elder abuse as follows:

*Physically striking or battering an elder
*Sexual abuse, including touching, fondling or sexual intercourse with an elderly party who is unable to provide informed consent, or is threatened or forced to consent
*Emotionally abusing an elder through threats of abuse or intimidation
*Confinement of an elderly person through restraint or isolation
*Passive neglect or the failure to provide for an elder’s basic needs
*Failure to protect an elder from harm

IL Nursing Home Issue – Chemical Restraints Are Still Pervasive

“Chemical restraints” are the use of drugs in order to restrain, or subdue, nursing home residents and patients. Drugs can be prescribed by doctors as a means to keep patients subdued or calm where they would otherwise be prone to physical and even violent outbursts in behavior. Patients with dementia or some type of psychosis, for example, can experience these episodes, and pose a safety issue to others around them, and of course themselves. These medications are often referred to as antipsychotic medications. In many instances, however, patients do not truly need these antipsychotic drugs, or do not need nearly the amount that they are given by nursing home staff. Sometimes staff will use antipsychotic medications to subdue patients who were not even prescribed the medication. This is where prescribed or non-prescribed drugs all of the sudden become a form of chemical restraint. Nursing home staff may simply use these chemicals improperly to make their own jobs easier so they keep patients subdued, and pharmaceutical companies certainly must not mind the continuing business.

AARP Study

A recent AARP article has highlighted the use of chemical restraints through antipsychotic drugs. It discusses the example of a woman who, after less than three weeks at a nursing home for treatment and recovery from a broken pelvis, and left “withdrawn, slumped . . . chewing on her hand, her speech garbled.”