Medicare Watch

Opportunities to Improve Quality and Reduce Costs of Care for Medicare Consumers in Long-Term Care

People with Medicare in long-term care facilities account for a disproportionate share of high Medicare spending for services, including hospitalizations, emergency room visits and skilled nursing facility care, according to three new reports released this week by the Kaiser Family Foundation. While the 2.2 million Medicare consumers in long-term care facilities for part or all of 2006 comprised approximately six percent of the Medicare population, they accounted for about 17 percent of Medicare spending for that year. Thirty-nine percent of Medicare spending for people in long-term care facilities was for hospitalizations, more than any other category of care.

The reports, both qualitative and quantitative in nature, together describe a “culture of hospitalization” in long-term care facilities. The studies cite clinical staff shortages as well as inadequate care coordination at facilities among the causes for hospitalization. The reports demonstrate the need for closer examination of Medicare spending associated with long-term care populations as a potential area for improving quality of care while at the same time reducing spending. Kaiser found that in 2006, about 24 percent of the hospitalizations for Medicare consumers in long-term care facilities were potentially preventable. They also found that a 15 percent reduction in hospitalizations of people with Medicare in long-term care facilities would produce approximately $1 billion in savings to Medicare in 2006 dollars, and a 25 percent reduction in hospitalizations among the same population would produce $1.7 billion in savings to the program.

Read the reports and watch the briefing, featuring CMS Administrator Dr. Donald Berwick, on Medicare spending for consumers in long-term care facilities.

Authorities Bust Massive Medicare Fraud Ring

Dozens of people across the country have been taken into custody on suspected involvement in one of the largest Medicare fraud schemes in history. Authorities say the alleged fraudsters are members of a nationwide crime ring that defrauded Medicare to the tune of $100 million in phony claims, and collected more than $35 million in payments over the past four years. The fraud ring’s members invented 118 medical clinics and stole the identities of doctors in order to file claims.

Read a Los Angeles Times article on the fraud ring.

Read the Federal Bureau of Investigation’s press release.

Medicare fraud reduction is a major priority of the Obama administration, and in recent months the Centers for Medicare & Medicaid Services (CMS) has been stepping up fraud-fighting efforts. The Affordable Care Act provides CMS with new tools to reduce fraud, while also calling for a shift in tactic. Instead of using the traditional “pay and chase” model, in which CMS identifies fraud by looking at claims that have already been paid, the agency will now focus on preventing fraud before it happens.

Learn more about the new tools to fight fraud.

CMS is also looking to enhance fraud detection through the Senior Medicare Patrol (SMP) program. This national program, which was recently awarded a $9 million grant, aims to prevent fraud by educating people with Medicare about the issue and teaching them techniques to recognize and prevent fraud in their own communities.

Read the CMS press release.

Learn more about SMP.

Medicare Reminder

Medicare pays for a limited amount of long-term supportive services.

Learn more about what Medicare covers.

If you have a chronic illness or disability and need extensive long-term supportive services, you will probably need to find resources other than Medicare to help pay for these services.

Some resources include:

• Medicaid
• Veterans Benefits
• Program of All-Inclusive Care for the Elderly (PACE)
• Long-Term Care Insurance and State Partnerships for Long-Term Care

Learn more about long-term care resources at www.MedicareInteractive.org.

Spotlight

Starting next month, people with severe disabilities will be able to access disability benefits faster. In a press release yesterday, the Social Security Administration (SSA) announced rules that will speed up the application process for these applicants.

Read SSA’s release.