Health and Disability

Last Friday afternoon, the Centers for Medicare and Medicaid Services (CMS) under the Department of Health and Human Services (HHS) published the highly anticipated 2016 Notice of Benefit and Payment Parameters (BPP) rule. The BPP addresses a number of consumer priorities for qualified health plans in 2016, ranging from rate review and language access to the essential health benefits (EHB) package and inclusion of essential community providers (ECPs). As Community Catalyst begins to sift through this important rule, we wanted to share information regarding the approach to the EHB package, which is the baseline set of benefits included in health plans both inside and outside Marketplaces.

HHS wants a uniform habilitative care definition. The National Association of Insurance Commissioners defines habilitative care as “health care services that help a person keep, learn or improve skills and functioning for daily living.” In terms of habilitative care as a benefit, however, the definition is less clear. In the first round of EHB development, states or insurers defined habilitative care, leading to highly variable definitions, some more restrictive than others. HHS proposes and seeks comment on a proposed definition (taken from the Glossary of Health Coverage and Medical Terms). Additionally, HHS clarifies that rehabilitative services are a distinct category of habilitative care – this is important so that limits on these services are separate, increasing consumer access to needed care. This is an opportunity for consumer advocates to provide comments to show their support of a new definition and/or offer feedback for strengthening the definition.

Children remain covered through 19th year. The rules make an important clarification that children continue to have access to pediatric services through their 19th year, ensuring continuity of care.

HHS highlights discrimination in benefit design. HHS warns insurers that it is prohibited to design plans in a discriminatory way and that HHS and/or state regulators may demand that insurers explain their benefit designs. HHS provides examples of discriminatory designs, such as limiting access to benefits based on age or placing drugs for a specific condition in the highest cost tier. Consumer advocates have an opportunity to weigh on developing a stronger, more transparent approach to holding insurers accountable.

The issue of financial firms buying health care assets to deconstruct them for cash is an important if complex issue. We all need to understand this....

http://goo.gl/XtqOvr

[It] would be around this time that regulators would begin to understand that the corporate guarantees that might stand behind the private equity firm's acquisition of the hospital system are a nullity.  The owners' resources are legally separated from those of the hospital system.  It would take years of litigation to pierce that corporate veil.  Thus, the commitments that have been made to the governmental and private constituents in the community are supported solely by the financial resources of the hospital system itself.  But that hospital system faces high debt service costs and obligations, other long-term cost commitments, and increasingly difficult revenue restrictions.

This appalling attempt to save money (it doesn't), or to shut up people with disabilities, through ridiculous rules about technology, is repeated every few years by ignorant bureaucrats in Washington and in the states.......

http://goo.gl/OEPN1v

Beginning in April, the Centers for Medicare and Medicaid Services (CMS) said beneficiaries could not get upgrades for the devices until after a 13-month rental period.

Then, the agency said that as of Dec. 1 they would no longer approve devices on which these functions were ever possible. In other words, even if the beneficiary wanted to pay for the add-ons, they couldn’t.

Medicare wouldn’t explain why they were doing this, not to PublicSource and not to about 200 lawmakers who sent a letter to CMS in September.

U.S. Rep. Tim Murphy, a Republican who represents parts of Southwestern Pennsylvania and is chairman of a subcommittee with public health oversight, sent a letter Nov. 4 demanding answers for what he called a “cruel and uncompassionate” act.

Two days later, Medicare backpedaled on the tough-guy approach it had taken for several months, calling for a 30-day public comment periodas it considers updating the coverage policy to include beyond-speech technology. The comment period ends Dec. 6.

CMS expects to issue revisions to the policy in July.

While some are taking this as a good sign, Lewis Golinker, director at the Assistive Technology Law Center in Ithaca, N.Y., is not as trusting, and he says there are other concerns that are still not addressed, such as routine denials of eye-tracking technology.

Our own Alison Hirschel.......

http://goo.gl/U3PgKt

Mild to moderate dementia is clearly a factor in much of the aggression, however, because it causes disinhibited behavior. Other factors, Pillemer says, include:

• Crowded conditions: The study found higher rates of mistreatment in more crowded facilities, and in areas within facilities where residents were more densely gathered.

• Understaffing: The study found higher rates of resident-on-resident aggression in nursing homes with lower staff-to-resident ratios.

• Nursing-home workers who are inured to the problem: “Staff can become somewhat blinded to this,” Pillemer says, “because of the frequency with which it occurs.”

• Conflict’s cyclical nature: “The negative behavior and effects are contagious,” Pillemer says. “Seeing these incidents causes other residents to be fearful, anxious, concerned—and that can lead to more of the behavior.”.........

Alison Hirschel, the elder law attorney for the Michigan Poverty Law Program and director of the Michigan Elder Justice Initiative, agrees. She cites cases in which relatively simple adjustments by nursing-home staff eased elders’ “difficult behaviors.” One man, a former police officer, had worked the night shift for decades before going into a nursing home. Staff expected him to sleep at night; but he found this impossible, and became frustrated and aggressive. Eventually the nursing aides figured out what would help. They gave him a clipboard and allowed him to wander around his unit at night. His frustration and challenging behaviors eased.

Another woman, who’d lived in an abusive orphanage as a child, did better when treated in ways that didn’t trigger terrifying memories. And a blind resident needed to hear from staff the steps they’d take as they bathed her.

Such adjustments by staff require knowledge of residents’ emotional needs and of their life histories — not just of residents’ medical charts. Acquiring such knowledge takes greater effort and skill, but Pillemer says that workers are generally eager to learn how to better address aggressive behaviors. “Staff feel very powerless to deal with this,” he says. “They don’t quite know how to handle it.”