Accessing Medicare and Medicaid: Times Are Changing

Recent headlines regarding the recent Medicaid cuts to Illinois long-term care providers only tell a portion of the dramatic story unfolding. Of course, for skilled nursing home providers, the reduction in Medicaid reimbursement is not welcome news, but ultimately no long-term care facilities will close as a result of this round of Medicaid cuts and balance sheets will remain stable. However, a little reported component of the recent budget cuts, causes worry among those who advocate for less institutional care for Illinois' older adults.

Reviewed in a prior post (here), in Illinois the Community Care Program (CCP) serves people age 60 and older and uses the Determination of Need (DON) tool to determine program eligibility and allocate services dollars. CCP is one of the largest programs of its kind in the nation, caring for 75,000 clients and growing at a fast pace (50% between 2004 and 2009).

A 2009  study prepared for the Illinois Department on Aging (which manages the program) determined that CCP is a "good deal" allowing a large number of frail oder adults at risk for nursing home placement to remain in the community at lower cost per person then if living in a nursing home. Unfortunately, the recent Medicaid cuts included raising the minimum DON score needed to access CCP, from a score of 29 to 37 (out of a scale of 0-100). Based upon utilization statistics published in 2009, approximately 22% of CCP clients will be no longer be eligible for this entitlement program. If I were a betting man, I would put money on the likelihood  that a lawsuit will be filed any day to prevent IDoA from implementing this change by providers belonging to the Life Services Network and the Health Care Council of Illinois. For elder care service providers, who cannot afford to provide uncompensated care, they can only offer best wishes and empathy to those older adults for whom these services are vital.

Meanwhile, research reported in the June edition of Health Affairs magazine reveals a disturbing trend of older adults being placed in "observation" status when in a hospital rather then being admitted.

the ratio of observation stays to inpatient admissions increased 34 percent [emphasis added], from an average of 86.9 observation stay events per 1,000 inpatient admissions per month in 2007 to 116.6 in 2009

To qualify for the Medicare covered stay in a skilled nursing facility, a Medicare enrollee must spend at least three consecutive midnights (i.e. the three-day rule) as an admitted inpatient in a hospital. Observation stays in a hospital are not sufficient to qualify for a Medicare covered stay in a long term care facility.

These unfavorable trends reflect the increasing pressure on government budgets and health care providers as they struggle to cope with a rapidly aging population. Regardless of whether cost containment measures are instituted by providers or legislators, the net effect on older adults and on those who who care for them are the same: you are on your own.

What do you think? Learn more on Twitter @AgingInChicago


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    Its just sad to see the government cut away at programs aimed to help the unfortunate.

  • Thank you for reading my blog and posting a comment. Your sentiment is shared by many. The question before us is whether Illinois is using best practices in addressing the needs of its vulnerable older adults?

  • 22%? Stunningly high. Although people prefer living in their homes- is it worth going without needed care and assistance.

    Would you explain (or refer us to a resource) the reason for the increasing trend for observational status in it a stick or carrot approach by cms for hospitals? Along with this uptick- how are snf's or assisted living settings responding? I imagine there might be a parallel uptick in
    private pay admissions to these settings too.

  • In reply to ombuds:

    Thank you for reading my blog so carefully. Currently, CMS (Medicare) monitors hospital readmission rates as a quality measure. Research by the Medicare Payment Advisory Commission (MedPAC) and others show that as many as 1 in 3 Medicare patients who leave the hospital will be readmitted within 30 days of discharge, and that a large portion of these readmissions can be avoided. Under the Affordable Care Act, CMS plans to implement a Hospital Readmissions Reduction Program that will reduce payments beginning in FY 2013 to certain hospitals that have excess readmissions for certain selected conditions.
    ALF's are not relevant to this discussion since they are not certified Medicare providers and do not provide any Medicare covered service.
    The capacity of a skilled nursing facility to care for an admitted Medicare resident without discharging the resident back to the hospital within 30-days will become a critical to securing a reputation for quality with a SNFs most important referal source: hospital discharge planners. Interestingly, discharge rates to hospitals is not currently a quality measure matrix on the Medicare nursing home compare website (, but that matrix is being redesigned and could be amended to include this data. I do not understand the connection private pay admissions and hospital readmission rates. Please elaborate and I hope you find this answer helpful.

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    Bruce Lederman has over 25 years experience in the senior care field as a direct care provider and thought leader. Bruce was CEO and president of his own firm that operated skilled nursing facilities in Illinois. He is a former nursing home administrator and has consulted to numerous elder care providers on planning for strategic growth as well as process improvement. Recently he served as board chair of CJE SeniorLife, a leading non-profit elder care provider in the Chicago area. Bruce is currently employed as chief strategy officer for a company providing skilled nursing services in communities throughout Illinois and Missouri.

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