Hospitals, Insurers Get Serious About Post-Discharge Care

There are some encouraging signs that the health care system is finally embracing the kinds of at-home care that can focus on the patients needs and keep them out of the hospital. Local insurance companies are working with a new provider, Landmark Health,(go to http://www.landmark to read more about this innovative company)  that sends doctors to the home on a regular basis to make sure that at-risk patients who have recently been in the hospital get the follow-up care and monitoring they need. Doctors making house calls returns us to the kind of person-centered care that we remember in our younger days. These changes are being driven by health care policies that seek to cut  re-admissions to the hospital within thirty days of discharge.

Hospitals around the state and country are also starting to embrace community supports navigator programs.  In addition to in-home medical care provided by doctors and nurses, it is also clear that community services and social support are essential to successfully remaining at home. Community supports patient navigators are being used in some areas to successfully assist patients, their families and caregivers to navigate the complex medical and social services systems following hospital discharge.

The primary tasks for a navigator include support in the hospital while preparing for discharge, including completion of health care proxy forms and advanced directives. Once the patient returns home, tasks include arranging follow-up appointments and transportation, medication self-support. Support also includes health literacy by providing information to support patients with self-care and linking to health promotion, chronic disease self-management programs and support groups.

Referral to community services through the  local Office for the Aging NY Connects program and other services is also a role of the navigator.

Secondary tasks including grocery shopping assistance, reading mail, arranging for needed durable medical equipment, home companionship, caregiver support and planning for any emergencies.

Medicare Whole Until 2028, Social Security 2034

The Trustees of Medicare and Social Security who are four members of the Obama Administration issued their annual report on Wednesday on the health of both programs.  The Trustees said that Social Security has enough funding to continue to pay full benefits to 2034 and would then be able to pay 79% of benefits.  (This is an important point since many times, media reports characterize the system as going “broke” when full benefits can’t be paid).  The trustees’  report said that combined employee-employer payroll taxes would have to be increased to 14.98% from the current 12.2% to make up for the shortfall or else raise payroll taxes, lift the cap on earnings subject to the taxes (currently $118,500)  or a combination of these changes or others.

The Social Security Trust Fund includes a retirement fund and a disability fund.  The disability fund was set to be short of money to pay full benefits  later this year.  The budget agreement passed by Congress earlier this year  extended its full solvency until 2023.

The Medicare Trust fund lost two years from last year’s report and Part A can pay full benefits through 2028 instead of 2030.  This is still much longer than projections a few years ago that showed funding for full benefits running out later in the current decade.  Rising health costs, largely driven by prescription drugs and the aging of the population led to the report saying that the Medicare funds will come up short two years earlier than projected last year.

Part B which covers doctor visits and outpatients services and Part D which covers prescription drugs are mandated by law to be fully funded and include a combination of beneficiary payments and federal budget expenditures.

“Social Security and Medicare remain secure in the medium-term,” said Treasury Secretary Jacob Lew. “But reform will be needed, and Congress should not wait until the eleventh hour to address the fiscal challenges given that they represent the cornerstone of economic security for seniors in our country.”


Federal Medicare Observation Status Notice Law Takes Effect August 6th

A new federal law passed last July requires that Medicare patients be given a notice,  a “MOON,”  Medicare Outpatient Observation Notice , between 24 and 36 hours after entering a hospital indicating whether they have been admitted or in “observation status.”  The law is set to take effect on August 6th.  The comment period ended on June 17.  New York State has already enacted a notification law like the federal law so we will be reviewing whether the new federal notice requirements will impact or supersede the state law.

The decision whether a patient is admitted to a hospital has a major impact on the beneficiaries’ finances since Medicare Part B rather than Part A would be covering observation or outpatient service.   A person not admitted for three days would have to pay out of pocket for any nursing home rehabilitation for example.  There have been cases  here in New York State which have received media attention of persons who suffered broken bones and needed rehab and who were in the hospital for more than three nights but not admitted before going to a nursing home for rehab.  These persons had to pay thousands of dollars for their nursing home visit.

The Center for Medicare Advocacy (CMA)  is critical of Medicare (CMS – Center for Medicare and Medicaid Services) saying that the notification is not required for some hospitals if they did not bill Medicare for observation status.   CMA says that the result is still the same for a patient who must pay out of pocket costs in a nursing home.   CMA also criticizes Medicare’s proposed MOON notice  because it only requires a determination of status to be given to the patient but it does not require hospitals to explain why a beneficiary has not been admitted but assigned to observation status.


New York State Leads Nation in Income Inequality

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A new report jointly released by the Economic Policy Institute in Washington and the Fiscal Policy Institute in Albany revealed that New York State leads the nation in income inequality.  The report says that in 2013, 31% of all income was earned by the top 1% of the population.  FPI says the report supports its advocacy for the state to extend the “millionaire’s tax” which is set to expire in 2017.

“Great income inequality is not a new phenomenon, and it’s not confined to large urban areas or only some parts of the nation,” said Ron Deutsch, Executive Director of the Fiscal Policy Institute (FPI). “It’s a persistent problem throughout the country—in big cities and small towns, in all 50 states. In the face of this national problem, we need policy solutions to jumpstart wage growth for the vast majority and sensible tax and budget policies in New York.”

Given New York’s extreme income polarization, FPI’s deputy director James Parrott emphasized that “The State’s top economic priority in 2017 has to be to have our leaders in Albany act to permanently replace the current “millionaires’ tax” with FPI’s 1% Plan for New York Tax Fairness that would add four new, high-end tax brackets.” The millionaires’ tax expires at the end of 2017 and if it is not extended, the wealthiest 1% of state taxpayers will get a $3.7 billion windfall at the expense of New York’s faltering budget. Non-resident commuters working in New York now pay 17% of that amount.

Regarding New York, the report’s key findings include:

The top 1 percent earned 45 times more than the bottom 99 percent in New York, the greatest disparity of any state. Connecticut ranked second with a top-to-bottom ratio of nearly 43. Wyoming was third, followed by Nevada and Florida.
The average annual income of the top 1 percent was $2 million (Table 1), and New York’s richest 1/100 of top 1% (“the 1% of the 1%”) had average incomes of $61.6 million, second to Connecticut’s $69.5 million.
Within New York State, only two counties—New York (Manhattan) and Westchester—have greater top-to-bottom income ratios than the state overall. In Manhattan, the average income of the top 1% ($8.1 million) was 116 times that of the 99% ($70,500), while in Westchester County, the average income of the top 1% ($4.3 million) was 54 times that of the 99% ($80,300).
High levels of income polarization are not limited to downstate New York. The third most income-polarized county was Saratoga, north of Albany, where the $1.8 million average income for the top 1% was 35 times that of the $51,500 average income for the 99%.
A three decade-long era of shared prosperity came to an end in 1979 when the 1%’s income share started to rise dramatically in New York and in every state in the United States.

Since 1979, the average incomes of the top 1% have grown by 272% in inflation-adjusted terms in New York, while the average incomes of the 99% rose a meager 5.4%.

FPI is a member of the Economic Analysis and Research Network and co-released the new report today in New York.

Legislature Leaves Albany to Uncertain Future

As usual the end of the New York State legislative session was a harried affair.  The session was supposed to end Thursday but didn’t end until early Saturday morning as leaders came to an agreement on several key issues and ignored others.  In the year when the two former leaders of the Assembly and Senate, Sheldon Silver and Dean Skelos, were sentenced to prison for financial self-dealing, there was no sense of outrage or urgency to try to restore the public’s trust. Only minimal ethics reforms were passed at the last minute to increase transparency in reporting.

Good government groups said that the ethics reforms didn’t get at the issues that Silver and Skelos were convicted of which were self dealing to financially benefit themselves and in Skelos’ case, his son, Adam.  The Legislature did not act on a proposal to limit outside income or to close the controversial LLC loophole that lets donors set up unlimited numbers of “limited liability corporations” which can make donations.  The only conclusion one can draw is that legislators want to keep it that way.  The Assembly though did previously approve a change regarding that issue.

Regarding other issues,  no action was taken on allowing the Uber and Lyft ridesharing services to operate in upstate New York.   Something could have and should have been done that would have improved transportation options for many in upstate areas.  Ridesharing would certainly benefit older persons as I have noted before.

Meanwhile, regarding some of the other issues of concern to human services advocates, the Legislature did take action to again reject what is known as “step therapy.”  This insurance practice requires patients to “fail first” on a drug specified by an insurer before having access to other drugs which a doctor believes is more effective.   Patient advocacy organizations rallied on this issues which pharmaceutical companies worked on in a less public way.

A bill was passed to allow for the creation of Advanced Home Health Aides who nurses could assign some functions.   Senior citizen and disability advocacy organizations pushed this legislation to allow persons to have greater options to live in the community and not have to go to a nursing home to get needed care.

Earlier in the week, the Governor and legislative leaders came to an agreement to expand access to breast cancer screenings including allowing time off for public employees for screenings.  For the second straight year, the Assembly passed a bill to subject electronic cigarettes to the provisions of the Clean Indoor Air Act but the Senate took no action.

Senator John DeFrancisco tried in the Senate to open up the paid family leave legislation to exempt businesses with under 50 employees.  However, that provision didn’t even get a Senate vote and advocates for the program feel the Senator was trying to score political points with the business community.

The aid in dying or physician assisted suicide bill died itself with no further action in the Assembly Codes committee.  It is doubtful the bill could have passed that committee as several Democrats were opposing it.  The bill will be back next year for another battle.

So, now Albany is in recess and the Legislature is unlikely to return until after the November elections.  The political landscape could look vastly different when the results come in.   Democrats are hoping to take control of the State Senate and have a number of opportunities in seats where Republicans are retiring or not running again.   And, 2017 could be a wild year in which New York City Mayor Bill de Blasio seeks re-election while fighting Governor Cuomo and both of their administrations remain under investigation by US Attorney Preet Bharrara.

How Assembly Voted on Safe Staffing Bill

The Assembly passed the Safe Staffing for Quality of Care Act A8580 on Tuesday by a vote of 108-32.  This bill has been around for a long time and is a priority for patient advocates, nurses and health care workers.   The bill requires minimum staffing levels in health facilities which must have a staffing plan.  Nurses can refuse to work if the minimum staffing level is not in place.    Health facilities said they need flexibility to manage the workforce, but advocates for the bill including StateWide Senior Action Council argued that inadequate staffing is directly responsible for medical errors and poor patient care.  This is the first time the bill has passed in the Assembly.  The Senate is not going to take it up but Assembly passage sets the stage for a big push for this bill if Democrats take over the State Senate in this fall’s elections.

It was mostly a party line vote though several Republicans voted for the bill including Claudia Tenney who is running for Congress in a central New York district to replace retiring Richard Hanna.   Democrat Robin Schimminger voted against the bill.

Floor Vote:


YEA/NAY: 108/32

Abbate Y Crespo Y Gottfried Y Lopez NO Palumbo NO Simon ER
Abinanti Y Crouch NO Graf Y Lupardo Y Paulin Y Simotas Y
Arroyo Y Curran NO Gunther Y Lupinacci Y Peoples-Stokes Y Skartados Y
Aubry Y Cusick Y Harris Y Magee AB Perry Y Skoufis Y
Barclay NO Cymbrowitz Y Hawley NO Magnarelli Y Pichardo Y Solages Y
Barrett Y Davila Y Hevesi Y Malliotakis NO Pretlow Y Stec NO
Barron Y DenDekker Y Hikind Y Markey Y Quart Y Steck Y
Benedetto Y Dilan Y Hooper Y Mayer Y Ra Y Stirpe Y
Bichotte Y Dinowitz Y Hunter Y McDonald NO Raia Y Tedisco NO
Blake Y DiPietro ER Hyndman Y McDonough Y Ramos Y Tenney Y
Blankenbush NO Duprey NO Jaffee Y McKevitt Y Richardson Y Thiele Y
Brabenec Y Englebright Y Jean-Pierre Y McLaughlin Y Rivera Y Titone Y
Braunstein Y Fahy Y Johns Y Miller Y Robinson Y Titus Y
Brennan ER Farrell Y Joyner Y Montesano Y Rodriguez NO Walker Y
Brindisi Y Finch ER Katz ER Morelle NO Rosenthal Y Walter NO
Bronson Y Fitzpatrick NO Kavanagh Y Mosley Y Rozic Y Weinstein Y
Buchwald Y Friend NO Kearns Y Moya Y Russell Y Weprin Y
Butler NO Galef Y Kim Y Murray NO Ryan Y Williams Y
Cahill Y Gantt Y Kolb NO Nojay NO Saladino Y Woerner Y
Cancel Y Garbarino NO Lalor NO Nolan Y Santabarbara Y Wozniak Y
Castorina NO Giglio NO Lavine Y Oaks NO Schimel NO Wright ER
Ceretto Y Gjonaj Y Lawrence NO O’Donnell Y Schimminger NO Zebrowski Y
Colton Y Glick Y Lentol Y Ortiz Y Seawright Y Mr Spkr Y
Cook Y Goldfeder Y Lifton Y Otis Y Sepulveda Y
Corwin NO Goodell NO Linares Y Palmesano NO Simanowitz ER

Opioid and Heroin Epidemic Rise to Top of State Agenda

As the State Legislature session heads to its conclusion this week the issue that has persisted at the top of the agenda and now is a priority for action is the epidemic of heroin and opioid painkillers.  This crisis has quickly spread across the country.  Just a year ago, Vermont Governor Peter Shumlin used his entire State of the State address to discuss it.  The number of deaths from heroin and opioid abuse has skyrocketed into an epidemic that some have compared to  the start of the AIDS epidemic in the early 1980s.  And, as I have noted before, the death rate for middle aged whites with only a high school education has risen causing the entire death rate in the country to increase for the first time in many years it was recently reported.  All of these facts are signs of terrible physical pain but also anxiety and even social and economic disruption.

Government leaders are searching for answers.  Have drug companies been pushing opioids?  Have doctors been overprescribing them?  Have patients been demanding them?  The answer to all three questions is yes.   Some have suggested that state efforts to carefully control and monitor narcotic prescriptions a few years ago with the I STOP legislation led to more people looking to get cheap heroin which drug dealers are happy to supply.

Today, Governor Cuomo and legislative leaders announced an agreement on legislation that would increase access to insurance coverage and expand treatment options and make them more widely available to those who are addicted.   More details will be revealed in the bill itself which will be voted on later this week before the session ends.

In the midst of tragedies like the terrorism in Paris, Brussels, San Bernardino and now Orlando, here is a homegrown tragedy right in our communities that government and the medical community and all of us in community organizations and churches should do something about.  Government action on this issue is a most basic responsibility.

End of Session Updates from Albany

***AARP is pushing for passage of the “Work and Save” Plan that would have the state facilitate a private retirement fund for those in the private sector without either a defined pension plan or a 401k plan.   AARP says over half of those workers have no access to a retirement savings plan.  The plan would be portable so that workers could maintain it if they took a new job.

***Action on approval of Uber and Lyft ride sharing services may be left to localities rather than the State Legislature adopting a statewide bill.  Of course, taxi unions are working feverishing against the bill.  Other issues include the level of insurance the Uber and Lyft drivers must carry.

***Health care unions and health advocates are still pushing for the safe staffing bill to pass which would require certain levels of staffing in health care facilities.  Rallies have been held on the issue during the session.

***The New York State Assembly again approved the single payer NY Health bill  on June 1 by a vote of 86-53.  There has been no action in the Senate.  A measure to enact such a plan is on the ballot in Colorado this fall.

***In May, the New York State Public Service Commission has approved a new low income energy policy that sets a goal of limiting utility costs to 6% of household income.  The proceeding  had been underway for over a year and included hearings around the state and comments submitted by many organizations. The low income proceeding was a  response to the fact that a large number of poor customers were still having their power disconnected because of affordability issues.  The 6% burden was calculated using the standard of 30% of housing costs with utilities costs being 20% of that.



Schneiderman Blocks Sale of Two Nursing Homes to Company that Sold Facility to Condo Developer

New York Attorney General Eric Schneiderman has blocked the sale of two nursing homes, the Greater Harlem Nursing Home and Rehabilitation Center and the St. Joachim and St. Anne nursing home, to the Allure Group.  Allure is the company that sold Rivington House, a nursing home for AIDS patients, to a private developer to build condos in a controversial move that has resulted in criticism of New York Mayor Bill de Blasio.    The De Blasio Administration is accused of removing a deed restrictions on the use of the facility after the company paid a substantial sum.

Schneiderman’s office released a letter it sent to the Allure group saying,

“The not-for-profit Rivington House entity, which the Allure Group came to control in 2015, did not, as was required under the Not-For-Profit Corporation Law, either seek to dissolve or to obtain approval for disposing of its nursing home operations at 45 Rivington Street,” it states.

Allure is saying that the company was going to keep the two facilities as nursing homes, but Schneiderman said that the company had said the same thing about Rivington House which now stands empty.  “Allure made clear and repeated promises to continue the operation of two nursing homes for the benefit of a vulnerable population — promises that proved to be false. Until we conclude our investigation, we will object to Allure buying additional nursing homes,” a spokesman for Schneiderman said.

I commend Attorney General Schneiderman for looking out for the public interest and blocking this company from possibly changing the stated nonprofit purpose of the nursing home.


NY Alliance Against Assisted Suicide Sends Letter to Assembly Speaker; California Law Takes Effects June 9th

The New York Coalition Against Assisted Suicide sent a  letter to Assembly Speaker Carl Beastie on Thursday saying that a full discussion of the issue is merited in the Assembly after the bill was passed last week in the Assembly Health Committee.  The bill is now in the Codes committee.  That committee will be a tougher one for the bill since there are a number of African American Democrats staunchly opposed in addition to many Republicans and two other Democrats who opposed it in the Health Committee.  It is unlikely the bill will be addressed by the full house this year.

The letter to Heastie said, “We hope you would agree that an issue such as this—one which completely upends existing medical practice and societal norms surrounding life and death—deserves thorough public consideration and debate.

“It is regrettable that such a substantial issue was discussed by the Health Committee in an “off the floor” meeting with very short notice and little public comment. Indeed, the closeness of the committee vote on this issue highlights the lack of public consensus and considerable bi-partisan concerns which the legislation raises. To note just a few that we believe have not been adequately considered:

  •   the importance of palliative medicine and medical advancements in relieving pain;
  •   the under-utilization of hospice care in New York;
  •   the danger that clinical depression plays in decision-making by those with a terminal illness;
  •   the detrimental effects such a law will have on New York’s suicide prevention efforts;
  •   the risks of coercion and abuse of our most vulnerable New Yorkers before and after the prescription is written;
  •   the negative influence of health care cost containment measures on end-of-life decision-making;
  •   the ethical and moral impact on the medical profession;
  •   the lack of medical or governmental oversight after the medications are prescribed.
  •   the risks of mistaken diagnoses and prognoses;
  •   the implications o changing fundamental medical-legal definitions of“cause of death”and “forensic evidence”;
  •   the concerning data from other states which have legalized the practice; and
  •   the dangerous societal implications for persons who are isolated, elderly, poor,chronically ill or disabled.

The letter was signed by James J.J. Hanson, President, Patients’ Rights Action Fund

Diane Coleman, JD President and CEO Not Dead Yet, Bruce Darling, President and CEO
Center for Disability Rights, Lindsay Miller, Executive Director, NY Association on Independent Living, Marilyn Golden, Senior Policy Analyst, Disability Rights Education and Defense Fund, Elizabeth Rosenzweig, Chapter Leader, Autistic Self-Advocacy Network of NYC, Beth Mahar, Director of Member Services, Hospice and Palliative Care Association of NYS, Drs. Janet and David Kim, NYS Co-Directors, American Academy of Medical Ethics

Michael Burgess Consultant, Generations of New York, Rev. Jason J. McGuire, Executive Director, New Yorkers for Constitutional Freedoms, Richard E. Barnes, Executive Director
New York State Catholic Conference, Rabbi Shmuel Lefkowitz Vice President, Agudath Israel of America, Johann Huleatt Outreach Director Bruderhof Communities

 In California, the bill was passed last summer in a special session which allowed it to bypass committees where there was strong opposition.  The program goes into effect on Thursday, June 9th.  It will take two doctor visits at least 15 days apart to cite that the patient has a terminal illness with less than six months to live.  A person could be referred to mental health counseling if a doctor feels the person needs an assessment first.