A Shift From Nursing Homes to Managed Care at Home

Faced with soaring health care costs and shrinking Medicare andMedicaid financing, nursing home operators are closing some facilities and embracing an emerging model of care that allows many elderly patients to remain in their homes and still receive the medical and social services available in institutions.

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Todd Heisler/The New York Times

Dr. Fredrick Sherman at Harlem PACE with Edna Blandon. “My spirits would drop if I went to a nursing home,” she said.

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The rapid expansion of this new type of care comes at a time when health care experts argue that for many aged patients, the nursing home model is no longer financially viable or medically justified.

In the newer model, a team of doctors, social workers, physical and occupational therapists and other specialists provides managed care for individual patients at home, at adult day-care centers and in visits to specialists. Studies suggest that it can be less expensive than traditional nursing homes while providing better medical outcomes.

The number of such programs has expanded rapidly, growing from 42 programs in 22 states in 2007 to 84 in 29 states today. In New York City, a program run by a division of CenterLight Health System, formerly known as the Beth Abraham Family of Health Services, has over 2,500 participants at 12 sites in the metropolitan area.

“It used to be that if you needed some kind of long-term care, the only way you could get that service was in a nursing home, with 24-hour nursing care,” said Jason A. Helgerson, the Medicaid director for New York State. “That meant we were institutionalizing service for people, many of whom didn’t need 24-hour nursing care. If a person can get a service like home health care or Meals on Wheels, they can stay in an apartment and thrive in that environment, and it’s a lower cost to taxpayers.”

The recent influx of adult day-care centers and other managed care plans for the frail elderly is being driven by financial constraints as President Obama and Congressional leaders seek hundreds of billions of dollars in savings in Medicare and Medicaid. Nursing homes, which tend to rely heavily on Medicare and Medicaid dollars, are facing enormous financial pressure — Mr. Obama’s proposed budget includes a $56 billion Medicare cut over 10 years achieved by restricting payments to nursing homes and other long-term care providers.

Nationally, the number of nursing homes has declined by nearly 350 in the past six years, according to the American Health Care Association. In New York, the number of nursing homes declined to 634 this January from 649 in October 2007, and the number of beds to 116,514 from 119,691.

Over the next three years, New York State plans to shift 70,000 to 80,000 people who need more than 120 days of Medicaid-reimbursed long-term care services and are not in nursing homes into managed care models, Mr. Helgerson said.

The move away from nursing homes was highlighted on Thursday when Cardinal Timothy M. Dolan announced that the Archdiocese of New York, one of the state’s largest providers of nursing home care, is selling two of its seven nursing homes and opening or planning to open seven new adult day-care centers over the next three years.

“Seniors and others who have chronic health needs should not have to give up their homes and independence just to get the medical care and other attention they need to live safely and comfortably,” Cardinal Dolan said in a statement before he opened a 250-patient program at Saint Vincent de Paul Catholic Healthcare Center in the South Bronx.

These new adult day-care centers, known around the nation by the acronym PACE — Program of All-Inclusive Care for the Elderly — provide almost all the services a nursing home might, including periodic examinations by doctors and nurses, daytime social activities like sing-alongs and lectures, physical and occupational therapy and two or three daily meals. All the participants are considered eligible for nursing homes because they cannot perform two or more essential activities on their own like bathing, dressing and going to the toilet. But they get to sleep in their own beds at night, often with a home health care aide or relative nearby.

The nonprofit groups that operate them receive a fixed monthly fee for each participant and manage their entire care, including visits to specialists, hospitalizations, home care and even placement in a nursing home. Because Medicare and Medicaid pay set fees instead of paying for specific procedures, center operators are motivated to provide preventive care to avoid costly hospitalizations or nursing home care.

Some elderly people, however, spurn PACE programs because under managed care, they would have to switch their physicians to those at the PACE center or in its network. Most elderly people want to live out their lives at home, a desire evident in interviews in the PACE center the archdiocese opened in 2009 in Harlem, which has a staff of three doctors and is visited regularly by a dentist, a podiatrist and a psychiatrist.

Todd Heisler/The New York Times

Rick Leeds, who teaches yoga and other wellness programs at the ArchCare PACE Center in Harlem, gives a massage to Edna Blandon, who goes to the center three times a week.

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Edna Blandon, 74, a diabetic weakened on her left side by a stroke who relies on a wheelchair, is transported by specialized van to the Harlem PACE center three days a week and appreciates that it provides not only a home care attendant but sends a nurse every two weeks to change pills in her pillbox and load a 14-day supply of insulin into syringes that she will inject.

“My spirits would drop if I went to a nursing home,” she said. “I love the fact that I can go home at night. There’s no place like home. I can sit down, look at the TV and go to bed when I want.”

James Harper, 70, a retired bank employee who spent 10 months at the archdiocese’s Kateri Residence, a nursing home on the Upper West Side, after a stroke paralyzed his right side, enjoys yoga breathing classes and discussions about black history. Yet he gets to spend nights and weekends with his wife, Albertene, and daughter, Traci, both of whom work during the day and are not around to care for him.

“This way I’m around people,” he said.

Dr. Fredrick T. Sherman, the Harlem PACE medical director, said that a 2009 study showed that PACE programs reduce lengths of stays in hospitals and delay assignments to nursing homes.

The archdiocese, whose new centers will serve a total of 1,500 people, receives an average of $4,000 a month from Medicaid for each participant and $3,300 from Medicare. By comparison, said Scott LaRue, the chief executive of ArchCare, the archdiocesan health care network, a month of nursing home care can cost the government $9,000.

Ultimately, the archdiocese hopes that half of its elderly clients will be served in community settings rather than in nursing homes, which currently serve about 90 percent of the archdiocese’s clients. For-profit companies have not yet moved into the managed care market, in part because of uncertainties about reimbursement formulas and the risks of taking on a nursing home population.

The PACE population tends to be younger than that at nursing homes, which raises the question of whether many PACE clients would really need nursing homes without PACE. Dr. Sherman replies to such skepticism by saying that his clients “need that level of service — the question is where they’re going to get it.”

Without PACE, he said, “they’re going to end up in nursing homes.”

Robert Pear and Christopher Reeve contributed reporting.

Local Civil Registry

Health-care costs: Debt talks boost Medicare reform plans – CSMonitor.com

Health-care costs: Debt talks boost Medicare reform plans

Health-care costs for seniors have been largely picked up by government. But their health-care costs could rise under various Medicare reform plans.

Members of Progressive Change Campaign Committee upset over potential cuts to Medicare, Medicaid, and Social Security walks to President Obama’s campaign headquarters to deliver 200,000 signatures from people who are refusing to donate or volunteer for his re-election campaign if Obama cuts entitlement programs,July. 15, 2011, in Chicago. The debt talks in Washington are breathing new life into plans that would raise health-care costs for seniors.

David Banks/AP

via Health-care costs: Debt talks boost Medicare reform plans – CSMonitor.com.

Baby Boomers are Doing More Than Simply Aging Gracefully

The baby boom generation continues to demand more out of life while maintaining a youthful outlook that defies growing old. According to a new poll conducted by the Associated Press and LifeGoesStrong.com, people born during the period spanning nearly two decades, between 1947 and 1965, believe that “you are as young as you feel” and they plan to keep on working and living instead of opting for passive retirement.

Among those boomers interviewed, a surprising number plan to work until they are at least 65, or even 70, just as long as their employment doesn’t require heavy physical strength, as a decline in strength seems to be a major concern. Otherwise, they have few worries about physical ailments overall. In fact, about 75 percent considered themselves to be middle-aged or younger in their sixties, with the average age at which they considered themselves old was 70.

The baby boomer generation engages in more exercise and eats healthier, in addition to drinking and smoking less than their parents did, which has gone a long way to preserve health, and prolong stamina. In addition, getting adequate sleep and downing more water has contributed to better health for this generation of positive thinkers.

The findings suggest that even after reaching advanced years, baby boomers are determined to hold on to their youth, because they have a lot of living to do. And, live is just what they can do, because in addition to better health, this generation has enjoyed more than their fair share of prosperity with soaring house values attained, pensions achieved, and plenty of time on their hands.

Of course, improvements in healthcare have played a major role in the ability of the boomers to keep living large. Finding themselves free of job and career obligations, many have the time and means to travel, and can also spoil their grandchildren like never before among generations past… read more through link.

via Baby Boomers are Doing More Than Simply Aging Gracefully.

Medical News: When Medicaid Paid Better, Kids Had More Dental Visits – in Public Health & Policy, Medicaid from MedPage Today

When dentists were reimbursed more for preventive visits, kids on Medicaid ended up in their chairs more often, likely because the increased compensation made them more willing to accept those patients, a government researcher said.

Still, the level of care for children with public insurance didn’t quite match that of those on private plans, according to Sandra Decker, PhD, of the National Center for Health Statistics in Hyattsville, Md.

More Medicaid children saw a dentist over six-month periods in 2000 and 2008 if the reimbursement was $30 rather than $20, Decker found.

But in the latter year, children and adolescents covered by Medicaid were less likely to have seen a dentist in the previous six months than were those covered by private insurance (55% versus 68%), Decker reported in the July 13 issue of the Journal of the American Medical Association.

“The results of this study support the claim that low Medicaid payment rates are associated with children and adolescents receiving less dental care than children covered by private insurance,” she wrote.

Although Medicaid removes many financial barriers to receiving dental care for children and adolescents, patients can’t access care if dentists decline to participate in Medicaid because of low payment levels or for other reasons, Decker wrote.

So Decker assessed data on Medicaid dental fees in 2000 and 2008 for 42 states plus the District of Columbia and merged them with data from the National Health Interview Survey on 33,657 children and adolescents, ages 2 to 17, from 2000-2001 and 2008-2009.

She found that on average, Medicaid dental payment levels didn’t change significantly in inflation-adjusted terms between those two time points.

The mean state Medicaid prophylaxis fee for children was $28.95 in 2000-2001 and $29.98 in 2008-2009.

In five states plus the District of Columbia, however, payments increased at least 50%.

In 2008-2009, more children and adolescents covered by Medicaid had seen a dentist in the past six months than did uninsured children (55% versus 27%).

Yet fewer children on Medicaid were seen compared with those covered by private insurance (68%).

In regression analyses, those who were covered by Medicaid or the Children’s Health Insurance Program (CHIP) were about 13 percentage points less likely than kids with private insurance to have seen a dentist, and uninsured children were about 40 percentage points less likely.

But Decker also found that changes in state Medicaid dental payment fees between 2000 and 2008 were positively associated with use of dental care among children and adolescents covered by Medicaid.

For example, a $10 increase in Medicaid prophylaxis payment level — from $20 to $30 — was associated with a 3.92-percentage-point increase in the chance that a child or adolescent covered by Medicaid had seen a dentist, she found.

“This study found that changes in state Medicaid dental fees between 2000 and 2008 were positively associated with changes in use of dental care among children covered by Medicaid,” Decker wrote. “As future expansions in Medicaid eligibility and insurance coverage more generally are contemplated and possibly implemented, more attention to the effects of provider payment policies on access to care, quality of care, and health outcomes may be warranted.”

She noted that the study was limited because the state Medicaid fees for child dental prophylaxis had to be estimated, and because data on variations in private insurance reimbursement rates were unavailable.

via Medical News: When Medicaid Paid Better, Kids Had More Dental Visits – in Public Health & Policy, Medicaid from MedPage Today.

Medicare is too generous. Seniors take advantage. – Medicare and More

Medicare does not require seniors to pay enough of their health care costs. Seniors go to the doctor too much.  Medicare supplement insurance makes these problems worse and contributes to out-of-control Medicare spending. These are the conclusions in a recent opinion piece in the Wall Street Journal titled, “Why Medicare Patients See the Doctor Too Much”.The authors also say the “Obamacare” changes to Medicare, which provide more free preventive care services to seniors, are bad because  they “further insulate seniors from costs and will drive up spending even more”.According to the authors:Medicare utilization is roughly 50% higher than private health-insurance utilization, even after adjusting for age and medical conditions. In other words, given two patients with similar health-care needs — one a Medicare beneficiary over age 65, the other an individual under 65 who has private health insurance — the senior will use nearly 50% more care.In the opinion of the authors, the answer to Medicare’s problems is:Since private health insurers are much better at controlling utilization and reducing fraud, why not turn to the private sector to resolve Medicare‘s excessive utilization? That’s what House Budget Committee Chairman Paul Ryan was trying to do with his premium-support model that would eventually shift Medicare beneficiaries into private health plans.The authors favor more choices for seniors, such as high-deductible health insurance options and plans that are more like those in the under-65 health insurance market. But the authors don’t mention that these high-deductible plans are designed for young, healthy people who are betting they won’t get sick and have to pay that $3,000 or $5,000 deductible before their insurance kicks in. That’s probably a good bet for a 30-year old. But what about a 70-year old?What are the chances a 70-year old will need to spend several thousand dollars on medical services each year? And what are the chances a senior will put off care because he has to pay 100% of the cost until he meets his deductible? Is it a good idea for seniors to put off care because they can’t afford it – or are too cheap to pay co-pays and deductibles? Is this a choice we want seniors to make? And is this good public health policy, or will it lead to sicker seniors and bigger medical bills for seniors and Medicare?

via Medicare is too generous. Seniors take advantage. – Medicare and More.

UCLA medical records: UCLA hospitals to pay $865,500 in settlement over breaches of celebrity patients’ records – latimes.com

UCLA Health System has agreed to pay $865,500 as part of a settlement with federal regulators announced Thursday after two celebrity patients alleged that hospital employees broke the law and reviewed their medical records without authorization.

Federal and hospital officials declined to identify the celebrities involved. The complaints cover 2005 to 2009, a time during which hospital employees were repeatedly caught and fired for peeping at the medical records of dozens of celebrities, including Britney Spears, Farrah Fawcett and then-California First Lady Maria Shriver.

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Violations allegedly occurred at all three UCLA Health System hospitals — Ronald Reagan UCLA Medical Center, Santa Monica UCLA Medical Center and Orthopaedic Hospital and Resnick Neuropsychiatric Hospital, according to UCLA spokeswoman Dale Tate.

The security breaches were first reported in The Times in 2008.

The violations led state legislators to pass a law imposing escalating fines on hospitals for patient privacy lapses.

After the law took effect on Jan. 1, 2009, state regulators fined Ronald Reagan UCLA Medical Center $95,000 in connection with privacy breaches that year that sources said involved the medical records of Michael Jackson, who was taken to the hospital after his death in June 2009.

The same month, the U.S. Department of Health and Human Services’ Office for Civil Rights began investigating alleged violations of the federal Health Insurance Portability and Accountability Act at the hospitals, according to the settlement agreement.

Investigators found that UCLA employees examined private electronic records “repeatedly and without a permissible reason” in 2005 and 2008, including an employee in the nursing director’s office, according to the agreement reached Wednesday.

The employee was not named in the agreement, and the hospital spokeswoman declined to identify who it was. But the timing and description of the alleged violations cited in the agreement suggest that it may have been Lawanda Jackson, an administrative specialist at Ronald Reagan UCLA Medical Center who was fired in 2007 after she was caught accessing Farrah Fawcett’s medical records and allegedly selling information to the National Enquirer.

Jackson later pleaded guilty to a felony charge of violating federal medical privacy laws for commercial purposes but died of cancer before she could be sentenced. Fawcett died of cancer in 2009.

Federal investigators faulted the hospital system for failing to remedy the problems, discipline or retrain staff.

“Employees must clearly understand that casual review for personal interest of patients’ protected health information is unacceptable and against the law,” Georgina Verdugo, director of the Office for Civil Rights, said in a statement Thursday, adding that healthcare facilities “will be held accountable for employees who access protected health information to satisfy their own personal curiosity.”

As a condition of the settlement, UCLA Health System was required to submit a plan to federal regulators detailing how officials would prevent future breaches. They agreed to retrain staff on privacy protections, formulate privacy policies, appoint a monitor to oversee improvements and report to regulators for the next three years.

UCLA Health System released a statement Thursday noting that, “Over the past three years, we have worked diligently to strengthen our staff training, implement enhanced data security systems and increase our auditing capabilities.”

“Our patients’ health, privacy and well-being are of paramount importance to us,” said Dr. David T. Feinberg, chief executive of the UCLA Hospital System. “We appreciate the involvement and recommendations made by OCR in this matter and will fully comply with the plan of correction it has formulated. We remain vigilant and proactive to ensure that our patients’ rights continue to be protected at all times.”

Tate said the money would be paid to federal health regulators.


via UCLA medical records: UCLA hospitals to pay $865,500 in settlement over breaches of celebrity patients’ records – latimes.com.

Herhold: Comprehensive immigration reform is a mirage – San Jose Mercury News

ver the last two weeks, America’s chattering classes have fixated on the story of Jose Antonio Vargas, a prizewinning ex-Washington Post reporter who grew up in Mountain View. In a piece in The New York Times, Vargas, 30, revealed a long-held secret: He is an illegal immigrant.

On the day that Vargas’ story ran, Democratic senators began a last brave push for “comprehensive immigration reform,” a mantra for those who want to fix the system.

The planks of this idea have always sounded solid: stiffer borders, more detailed checks of IDs by employers, and a path to citizenship for millions in this country illegally.

It’s hard to question an idea this well-meaning. But as I look at the politics of this issue, I’m convinced comprehensive immigration reform is a mirage, a flash of water in the desert.

It won’t happen because too many people have a stake in the status quo. And the effort probably won’t help Vargas.

Begin with the politicians. In tough times, undocumented immigrants offer a convenient punching bag for Republicans. In the GOP version, the “illegals” steal jobs, weaken schools, grab benefits. Reform would remove a handy cudgel against Democrats.

By the same token, Democratic politicians realize that the boom in immigrants will benefit them even without reform. With new generations trending Democratic, Arizona, Nevada and even Texas could become reliably blue states.


Fundamentally, economics speaks against reform. As long as the disparity in wages looms large between the U.S. and poorer nations, resourceful people will strive to find a way into the country. Employers seeking cheap labor won’t examine documents too closely.

Intriguingly, The New York Times reported Wednesday that a combination of forces — better education, rising border crime and smaller families — has dramatically slowed the Mexican migration to America.

But my point still holds: If you erect a 90-foot electrified barrier, or something comparable, it can’t be good for the job security of border guards or the bottom line of their SUV makers.

Even local police have an interest in preserving things as they are now. A police detective can use the threat of deportation to help crack a case.

In sum, we have a well-intentioned idea endorsed by lots of good people who face quiet but enormous opposition from powerful forces with reasons not to change anything.

It’s as if in the wake of Prohibition, we said, “We need comprehensive alcohol reform. We need to require folks to drink responsibly, punish those who don’t, and limit hard liquor.” Sensible. And unworkable.


What’s the answer? Well, first, we ought to have a clear understanding of the problem. We should understand that immigration, both legal and illegal, has brought enormous benefits to America.

Very often, the undocumented are doing work that Americans don’t want to do. They work hard, raise families, buy American goods. Our phobia about illegal immigration reflects our economic fears.

The perfect shouldn’t stall the good. “Comprehensive immigration reform” sounds like a sweeping solution. But if it hinders more modest approaches like the Dream Act, which would allow citizenship for people brought here as children — people who show drive, like Vargas — it becomes not just a mirage. It approaches folly.

via Herhold: Comprehensive immigration reform is a mirage – San Jose Mercury News.

Study: Medicaid Coverage Makes a ‘Big Difference’ – Health Blog – WSJ

A new research paper gives the clearest answer yet to a key question: how are people affected by gaining health insurance?

A study of people who got new Medicaid coverage shows that they received significantly more care, including preventive checks and hospital admissions, improved their financial situation, and felt better. “Having Medicaid made a big difference in many dimensions,” Amy Finkelstein, an MIT economics professor and lead author of the paper, tells the Health Blog.

The issue is more important than ever, with a huge new influx of Medicaid beneficiaries and other newly-covered people expected in 2014 due to the health-overhaul law. But it’s always been tough for researchers to get a good picture of the effects of new health coverage. In the real world, there are likely inherent differences between people with and without insurance, making it hard to get an answer by simply studying those groups.

The new paper, published by the National Bureau of Economic Research, focuses on an Oregon program that let certain low-income adults qualify for Medicaid through a random lottery process. That conveniently established the conditions for the gold standard of scientific research, a randomized controlled trial. The only similar study to take place in the U.S., Rand’s Health Insurance Experiment, which began in 1971, looked just at the effects of different levels of out-of-pocket charges on insurance enrollees.

The new study used surveys, hospital discharge data and other sources to compare the roughly 30,000 people who were selected in the lottery to 45,000 people who signed up and didn’t get chosen. It examined approximately the first year of coverage.

Overall, health-care expenditures for those who got coverage went up by roughly a quarter, which translated into about $778 a year. Those who received Medicaid were around 60% more likely to get mammograms — the proportion receiving the screening test rose to nearly 50% from 30%. Medicaid recipients were 55% more likely to have a regular primary-care doctor. They were also in better shape financially, roughly 25% less likely to have an unpaid medical bill sent to collections.

Those who got Medicaid were also far more likely to report themselves in good or excellent health. That may set up a contrast with the Rand research, which generally showed little difference in health outcomes for those with more generous insurance, even though they used more health services.

“If it holds up, it would be a very important difference,” said Joseph Newhouse, a Harvard professor who was also an author of the new study. He said the researchers plan to look at actual health outcomes for the Oregon population, as opposed to self-reported status, in a future paper.

But emergency-room admissions didn’t decline –  and actually rose slightly, though not significantly — for those who got Medicaid.

Also, the researchers are cautious about whether their results can be extrapolated to the huge new population of Medicaid beneficiaries that will be created by the health-overhaul law; the folks in Oregon may not be nationally representative.

Image: iStockphoto

via Study: Medicaid Coverage Makes a ‘Big Difference’ – Health Blog – WSJ.

Determining quality of health care from York-area hospitals’ performance – York Dispatch

Be it clothing or cars, potential buyers usually have an idea of how good products are and how much they cost before they buy them.

Then they buy what’s believed to be the best quality product for the best possible price.

Determining quality of health care from York-area hospitals’ performance – York Dispatch.

Top 10 Health Care Reform Jokes – Best Political Jokes About Health Reform

Top 10 Health Care Reform Jokes – Best Political Jokes About Health Reform.