Family Caregiver Alliance's Policy Digest

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A Newsletter of FCA's National Center on Caregiving

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August 8, 2012

Volume XII, Number 16

I nthis issue section head

State Legislation, Policy & Reports 

  1. TN: State Creates New Category Of Medicaid LTC With $15,000 Annual Limit For Enrollees  More...
  2. Washington DC: Grass-Roots Village Movement Enables Aging In Place More...
  3. CA: Pilot Uses Health Navigators To Assist Patients With Discharge, Care Coordination  More...
  4. Profile Of First Four States To Receive Approval For Medicaid Health Homes: MO, RI, NY OR  More...

Federal Legislation, Policy & Reports 

  1. GAO Report: Some Medicaid Health-Care Providers Continue Being Paid Despite Not Paying Taxes  More...
  2. OIG Report: One In Four Home Health Agencies Exceeded High Billing Thresholds In 2010  More...
  3. Report: Medicare Should Allow Advanced Practice Nurses To Certify For Home Health And Hospice  More...
  4. CMS Releases Two Resources Focused On Managed Care  More...
International News 
  1. New Report: How World Can Respond To Aging Society  More...
  2. Singapore: Study Finds That One In Three Discharged Patients Are Cared For By Their Spouse  More...

Research Reports & Journal Articles

  1. Study: Every 176 Additional People Covered Under Medicaid Leads To One Fewer Death Annually  More...
  2. Study: Cause Of Death Data From Death Certificates May Not Be Accurate  More...
  3. Report:  Allowing Caregivers To Contribute To IRA May Alleviate Some Financial Pressures For Women  More...

Conferences & Trainings

  1. Webinar: Caregiver Assessments: Practice Considerations For System Change  More...
  2. Webinar: How To Pay For Long-Term Care Without Going Broke  More...
  3. Webinar: Funding Sustainability For Lifespan Respite Program, Part II: Examples From The States  More...
  4. Webinar Series: The Art Of Fostering Relationships And Networks Of Support For People With Disabilities  More...
  5. Webinar: Medicaid Managed Care: A Perspective From State Advocates  More...
  6. Application For 2012 Rosalinde Gilbert Innovations In Alzheimer's Disease Caregiving Legacy Awards Now Available  More...

Funding, Media & Miscellaneous 

  1. Blog: Is Assisting A Spouse With Suicide Informed By Love Or Despair?  More...
  2. MN Attorney General Forces Hospital Debt Collector Out Of State  More... 

Research Registry  


If you are interested in having your study listed in FCA's Research Registry, please contact [email protected] 


A note to our readers: Caregiving PolicyDigest will go on a brief break after this issue and will return later this summer.  


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Kaiser Health News reports that Tennessee is re-structuring its Medicaid long-term care program to provide care for people who the state believes could live in the community with $15,000 worth of support or less each year.  While state officials believe this new category will help people who don't need the full level of support offered through institutional care or through home and community based services (with a current price tag of $55,000 a year), advocates question if the $15,000 cap will provide a sufficient level of services.  This move follows a similar shift the state made in 2009 to shift more spending to home and community based services, which resulted in twice as many people receiving HCBS instead of nursing home care.  The state is changing its assessment process from analyzing activities of daily living to instead using a weighted point system that is structured to make qualifying for nursing home care more difficult.  The Assistant Commissioner of TennCare explained to Kaiser Health News that the department's analysis found that 40% of elderly Medicaid patients receiving HCBS prior to the 2009 change were spending less than $15,000 per year, and so she believes enrollees will receive "an appropriate level of benefits."  For more information, visit:

Kaiser Health News: "Tennessee raises bar for some Medicaid coverage of nursing home care" 


The Washington Post recently profiled two people in the Washington DC area who are aging in place with the assistance of a local senior village. The older adults pay a membership fee each year, ($700 for a couple or $500 for a single person) and are then connected to a support network that enables them to remain in their home.  A network of volunteers can provide services including transportation to doctor visits, errand running, and light repairs such as light bulb replacement. The first organization was started in 2002 in Boston, and there are now 70 in the U.S. with plans for more in development. For more information, visit:

HealthyCal recently highlighted the second phase of a pilot program in Santa Cruz County that is working with vulnerable patients to assist them with hospital discharge, medication management, and care coordination.  The pilot is being run by the Health Improvement Partnership of Santa Cruz County, a coalition of hospitals, doctors, philanthropists, and social service agencies.  During the first phase of the pilot, which lasted 15 months, a health navigator worked with 192 patients who were hospitalized.  One of the primary activities was helping them to obtain health insurance coverage in MediCruz Advantage, a low-cost county health plan. During the second phase of the pilot, a health navigator will work with 250 people annually to help with coordinating their care during and after a hospital discharge, and this may include transportation, housing, medications, and referrals for mental health. The program is projected to cost $900,000, though it has the potential for large cost savings.  Data from a nonprofit health plan in the area found that 8% of the plan members accounted for 75% of the plan costs.  Hospital readmissions, also costly, were reduced by 10% for patients in the initial phase of the pilot.  For more information, visit:

A new brief from the Kaiser Commission on Medicaid and the Uninsured focuses on an optional program included in the Affordable Care Act to implement health homes for people with multiple chronic conditions.  While six states have been approved by the federal government for this program, this brief profiles the first four states to receive approval: Missouri, Rhode Island, New York, and Oregon. To qualify for this program, patients must have at least two chronic conditions, or have one chronic condition and be at risk for another, or have one serious and persistent mental health condition.  Services provided under the home health plan can include care management, care coordination, transitional care, patient and family support, and using health information technology.   States receive a 90% FMAP for the first two years of the program.  The brief examines how the states have addressed several key issues with their programs, including geographic availability, what patients are targeted, designated providers, payment, and coordinating with managed care organizations.  Challenges with the program include working with managed care organizations, determining how this program fits into initiatives to improve care for dual eligibles, and competing priorities (i.e. state health exchanges) for state Medicaid agency staff.  The brief also includes a chart comparing the approaches taken by the four states.  For more information, visit:


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GAO Report: Some Medicaid Health-Care Providers Continue Being Paid Despite Not Paying Taxes


The Washington Post reports that a new report from the GAO found that there are thousands of health-care service providers that are paid by Medicaid for providing services despite the fact that they are delinquent on paying their  taxes.  While the IRS is able to block payments in Medicare using an ongoing levy, it can't use the same strategy in Medicaid because the IRS has determined that the money the federal government provides to states for Medicaid does not qualify as federal payments.  Some state officials raised concerns about using continuous levies in Medicaid based on their previous experiences with the IRS using one-time levies.  Providers in Texas, New York, and Florida were analyzed, while California's Medicaid data was deemed not reliable enough for the study.  The GAO found that 7,000 providers who received $6.6 billion from the federal government for services also owed the government a total of $791 million in unpaid taxes in 2009.  If the IRS were able to collect taxes from the providers in these three states, the GAO estimates they could recover $22 to $330 million.  For more information, visit:

Washington Post: "Medicaid health-care providers still paid by U.S. despite tax debts" 

GAO: "Providers in Three States with Unpaid Federal Taxes Received Over $6 Billion in Medicaid Reimbursements" 


OIG Report: One In Four Home Health Agencies Exceeded High Billing Thresholds In 2010


The Office of the Inspector General (OIG) at HHS released a report that analyzed the $19.5 billion in Medicare payments made in 2010 to the 11,203 home health agencies (HHA) that provided care for 3.4 million Medicare beneficiaries.  The report found that $5 million worth of these claims should not have been paid because they overlapped with inpatient hospital stays or skilled nursing facility stays and/or because the services were allegedly provided after the beneficiary had passed away.  The OIG report also suggests that about one out of four HHAs exceeded a threshold which indicates unusually high billing.  Recommendations to CMS include improvements in claims processing to prevent inappropriate payments for overlapping services, more bill monitoring, lowering the 10% cap on outlier payments, and possibly implementing a moratorium on new HHA enrollments in Florida and Texas.  The report indicates that 80% of the occurrences where billing exceeded one of six thresholds occurred in Texas, Florida, California, and Michigan.   For more information, visit:

OIG: "Inappropriate and Questionable Billing by Medicare Home Health Agencies" 


Report: Medicare Should Allow Advanced Practice Nurses To Certify For Home Health And Hospice

A new report from AARP's Public Policy Institute focuses on a recommendation included in the 2011 Institute of Medicine report that suggested allowing advanced practice registered nurses (APRN) to certify people for Medicare home health and hospice services.  Under current rules, only a physician may certify a patient for these services.  The author explains that Medicare's approach to APRNs and nurse practitioners (NP) is somewhat inconsistent, with NPs allowed to act as attending physicians for hospice patients and APRNs are allowed to certify patients for post-hospitalization services in skilled nursing facilities.  Beyond the fact that NPs and APRNs are already familiar with the services and patients and could help alleviate time pressure on doctors, the author explains that allowing APRNs to certify for home health could save Medicare $129 to $309 million over the next ten years since non-physician providers receive a 15% lower payment from Medicare. For more information, visit:


AARP PPI: "Removing Barriers to Advanced Practice Registered Nurse Care: Home Health and Hospice Services"  

CMS Releases Two Resources Focused On Managed Care

In a recent bulletin, CMS highlighted two new resources focused on managed long-term services and supports (MLTSS).  The first resource is a white paper that includes an inventory of all current MLTSS programs as well as projected programs through January 2014.  The report includes various ways that states have structured their MLTSS systems.  The second resource is an online tool that provides state guidance on program design, Medicaid authorities, and other information that will be helpful for managing MLTSS.  The online tool includes links to sample contracts, and examples of state structures for MLTSS.  For more information, visit:


CMS Information Bulletin  



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New Report: How World Can Respond To Aging Society

A new report was released at the Global Health Policy Forum that focuses on how the world society can plan for the future as a growing percentage of the world's population ages and will need long-term care.  The report is authored by the Ageing Societies Working Group and the International Longevity Centre (UK), and the introduction notes that one fourth of the world's population (about two billion people) will be age 60 or over in 2050.  The report focuses on four areas: the financing of long-term care, supporting family caregivers, prevention and self-management, and providing care in the home and community as compared to institutional care.  Challenges with relying on informal care include more women entering the workforce,  migration leading to families not living together, declining fertility rates, and in sub-Saharan African, the AIDS epidemic, which has led to "orphaned" parents.  As part of their work, the authors intend to create and refine an Ageing and Health Sustainability Index that will allow countries to benchmark their systems against each other.  For more information, visit:

Report: "Creating Sustainable Health and Care Systems in Ageing Societies" 



Singapore: Study Finds That One In Three Discharged Patients Are Cared For By Their Spouse


A recent study conducted by the Changi General Hospital highlights the important role that family caregivers, especially spouses, play in long-term care in Singapore.  The study of 3,000 patients, conducted between 2008 and 2010, was highlighted by  Twenty-eight percent of discharged patients report that their primary caregiver is their spouse, and 57% of these spouses are aged 65 or older.  The hospital started a 12-member Aged Care Transition team in 2008 that plays a coordinating role between the patient, their family caregiver, hospital staff, and outside community partners. Team members follow up with the patients on the phone and with home visits for two months after the discharge, and then make referrals to community partners. Other supports for Singapore family caregivers include the Asian Women's Welfare Association Centre for Caregivers, which provides emotional support.  An advocate interviewed for the article suggested that policy changes would also help caregivers, for example, by expanding a tax credit for maids that is currently only offered for new parents, but could also be offered for adult children caring for an aged parent.  For more information, visit: : "Most elderly patients cared for by spouses" 



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Study: Every 176 Additional People Covered Under Medicaid Leads To One Fewer Death Annually


Washington Health Policy Week in Review highlighted a study conducted by the Harvard School of Public Health that analyzed how extending Medicaid coverage affected mortality rates for childless adults in Arizona, Maine, and New York.  This research is especially timely as several governors have publicly suggested that they may restrict eligibility for Medicaid as a result of the recent Supreme Court ruling.   In these three states, Medicaid eligibility was expanded to childless adults and this was correlated with a 6.1% drop in mortality as compared to neighboring states that did not expand their Medicaid programs.  Death rates fell the most for older adults, minorities, and people in poorer communities, with New York experiencing the biggest decline.  For more information, visit:

Washington Health Policy Week in Review: "Medicaid Expansions Linked to Fewer Deaths"  


Study: Cause Of Death Data From Death Certificates May Not Be Accurate

Reuters reports that a study recently published in the Journal of American Geriatrics Society earlier this summer calls into question whether cause of death data is accurate for older patients.  Under current World Health Organization guidelines, only one cause of death is listed on a death certificate.  The researchers conducted the study because they suspected that the system may not give accurate information when determining the cause of death for a geriatric patient who may die from a combination of factors. Cause of death data is important because it can play a role in how research money is divided.  After comparing death certificates, Medicare claims, and secondary causes of death, the authors determined that dementia was a factor in 13% of deaths.  In contrast, if the study had solely relied on death certificates, only 3% of the population showed dementia as a cause of death. The lead author, Dr. Mary Tinetti, explained to Reuters, "Dementia was the second most common contributor to death, which is a much higher proportion than when only a single cause of death is considered."  For more information, visit: 


Reuters: "Death certificates may not tell the whole story"

Journal of the American Geriatrics Society (Abstract is Free): "Contribution of Individual Diseases to Death in Older Adults with Multiple Diseases"   



Report:  Allowing Caregivers To Contribute To IRA May Alleviate Some Financial Pressures For Women


The New York Times Bucks blog recently highlighted a new report from the GAO focused on the larger financial challenges that women face in retirement.  The report included analysis of two national surveys, a literature review, and interviews with retirement experts. While women gained greater access to employer-sponsored retirement plans in the past two decades, they have contributed at lower levels to their retirements than men.  For women who are nearing retirement age, divorce, widowhood, and unemployment all had large negative impacts, for example, divorce almost halved their income (a reduction of 41%), while widowhood reduced income by 37%.   Policy options to address financial security for women includes allowing caregivers to contribute to their IRAs based on their adjusted gross income in the year before they became a caregiver.  Caregiver credits in Social Security are also cited as a possible option, though the authors note that these credits may not benefit lower-income women who are unable to stop working in order to provide care. For more information, visit:


New York Times: "Options for Providing Women With a More Secure Retirement"

GAO: "Women Still Face Challenges"  




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Family Caregiver Alliance is sponsoring a webinar on August 23 from 12:00 to 1:00PM (Pacific) that is the second webinar in a two-part series focused on the assessment of family caregivers.   The two presenters will discuss challenges in expanding assessment beyond the care recipient to also include the caregiver, challenges of administering a structured caregiver assessment, and practical issues that can arise when using assessment tools.   Dr. David W. Coon, and Jo McCord, a family consultant at Family Caregiver Alliance who works directly with family caregivers, are the two presenters.   For more information, or to register for this free webinar, visit: 


FCA: "Caregiver Assessment II: Practice Considerations for System Change"




Family Caregiver Alliance and Harold L. Lustig, a financial advisor and author, are sponsoring a webinar on August 16, from 11:00am to 12:30pm (Pacific) focused on strategies to pay for long-term care. Lustig is the author of Naked in the Nursing Home, which he wrote after his experience caring for his parents.  Participants will learn about Medicaid/Medi-Cal mistakes to avoid, VA benefits, when to seek legal help, and how families can plan ahead for the cost of long-term care.  For more information or to register for the webinar, visit: 


FCA: "How to Pay for the High Cost of Long-Term Care Without Going Broke" 



Webinar: Funding Sustainability For Lifespan Respite Program, Part II: Examples From The States


ARCH Respite is hosting a webinar on Tuesday, August 14, from 3:00 to 4:30PM (EDT) that will focus on ways to create sustainable funding plans for Lifespan Respite Programs.  This is the second webinar in this series, and will also touch on highlights from the ARCH Guide to Federal Funding and Support Opportunities for Respite.  The webinar will be most useful for Lifespan Respite grantees, but will also be applicable to people who are interested in sustainable funding for respite programs.  For more information, or to register for the webinar, visit: 


ARCH Webinar: Funding Sustainability for Lifespan Respite Programs, Part II: Examples from the States 



Webinar Series: The Art Of Fostering Relationships And Networks Of Support For People With Disabilities 


TASH is sponsoring a webinar series this fall that is focused on the art of fostering relationships and networks of support for people with disabilities.  There are seven parts to the webinar series, which is intended for community support professionals and agencies that are interested in organizational change or finding innovative service approaches.  Topics include "Choreographing Your Way through the Community," "Get Out! What It's Like to Leave Center-Based Practices and How to Get the Feel for Footwork with Community Partners,"  "So You Think You Can Dance? Taking Your Show on the Road: A Summary and Call to Action!" and others.  The series costs $35 for TASH members and $55 for non-TASH members, and the webinars are recorded and can be replayed.  For more information, or to register, visit:


TASH: "Dancing with Community: The Delicate and Necessary Art of Fostering Relationships and Networks of Support for People with Disabilities" 



Webinar: Medicaid Managed Care: A Perspective From State Advocates


The Friday Morning Collaborative is sponsoring a webinar on August 17, 2012 from 2:00-3:30PM (EST) that will include presentations from state advocates about their experiences with Medicaid managed care.  Presenters include Gordon Bonnyman, from the Tennessee Justice Center; Valerie J. Bogart from Selfhelp Community Services, Inc; and Mitch Hagopian from Disability Rights Wisconsin.  For more information, or to register, visit:


Friday Morning Collaborative: State Advocate Experiences in Managed Long-Term Services and Supports 



Application For 2012 Rosalinde Gilbert Innovations In Alzheimer's Disease Caregiving Legacy Awards Now Available


With continuing support from The Rosalinde and Arthur Gilbert Foundation, Family Caregiver Alliance (FCA) is pleased to oversee the annual Caregiving Legacy Awards program now in its fifth year. The program stimulates innovation in the field of Alzheimer's disease caregiving by recognizing and rewarding those efforts which lead the way in addressing the needs of Alzheimer's disease caregivers.  The deadline to apply is August 17, 2012.  For more information, visit: 


Award Application 


Funding, Media & Miscellaneous banner

Blog: Is Assisting A Spouse With Suicide Informed By Love Or Despair?


The New Old Age blog recently addressed the issue of people assisting their ill spouses to die and profiles two recent cases of husbands who had assisted their chronically ill wives to commit suicide. In one case, the husband had originally interrupted his wife's suicide attempt, but a few months later, he had a change of heart and assisted her.  In another case, the husband was taken to jail for the night for assisting his wife to die, but prosecutors declined to press charges.  Several experts interviewed for the post suggest that in many cases isolation is leading to depression, which is leading to people wanting to die.  However, some of the nearly 200 reader comments suggested that ending chronic pain and suffering are also motivating factors.  For more information, visit:

New Old Age: "A Desperate Act, Born of Depression"


MN Attorney General Forces Hospital Debt Collector Out Of State


Kaiser Health News reports that Minnesota Attorney General Lori Swanson has reached a settlement agreement with Accretive Health for their improper bill collecting practices, which included accosting hospital patients while they were waiting services in the Emergency Room. Accretive Health agreed to pay a $2.5 million fine, and stop doing business in Minnesota for at least six years unless the Attorney General allows them back sooner.   Despite signing the settlement, Accretive Health's attorney said that they were leaving the state because they didn't want to do business in Minnesota because of the rough treatment they received from the Attorney General.   For more information, visit:


Kaiser Health News, Minnesota Public Radio, NPR: "Hospital Debt Collector Settles Minnesota Case For $2.5 Million"



To find caregiver support services in your state, visit FCA's Family Care Navigator

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The National Center on Caregiving at Family Caregiver Alliance works to advance the development of high-quality and cost-effective policies and programs for caregivers in every state in the country. The National Center is a central source of information and technical assistance on family caregiving for policymakers, health and service providers, program developers, funders, media and families. For questions or further information about the National Center on Caregiving, contact [email protected] or visit the Family Caregiver Alliance website at

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Caregiving PolicyDigest is a publication of the National Center on Caregiving at Family Caregiver Alliance, 785 Market Street, Suite 750, San Francisco, CA 94103.