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Anyone who’s fought cancer knows that it’s not just scary, but pricey, too.

“A lot of my patients cry — they’re frustrated,” says Dr. Ayalew Tefferi, a hematologist at the Mayo Clinic. “Many of them spend their life savings on cancer drugs and end up being bankrupt.”

The average U.S. family makes $52,000 annually. Cancer drugs can easily cost a $120,000 a year. Out-of-pocket expenses for the insured can run $25,000 to $30,000 — more than half of a typical family’s income.

“These drug prices are completely unsustainable,” Tefferi says. “Pharmaceutical companies are in greed mode, and it’s sad. It’s what I call completely unregulated.”

According to a 2013 study, these steep drug prices cause about 10 to 20 percent of cancer patients to skip or compromise the prescribed treatment. Another study found that the launch price of cancer drugs, adjusted for inflation, increased by an average of $8,500 a year between 1995 and 2013.

To make the point, Tefferi recruited 117 other doctors from across the U.S. who share his concerns. Together, they agreed on seven recommendations to make cancer drugs affordable that they want the federal government to consider. The recommendations are laid out in a commentary Thursday in the journal Mayo Clinic Proceedings.

The proposals include allowing the importation of cancer drugs across the U.S. border. Drugs are cheaper in other countries, like Canada, they argue, so why not let people with cancer bring them in for personal use?

They also favor legislation that would stop drug companies from delaying access to cheaper generic versions of their drugs. Tefferi points to Gleevec, or imatinib generically, as an example. It’s used to treat chronic myelogenous leukemia and some other cancers. “That drug should have gone generic three or four years ago,” he says. “But Novartis is doing all sorts of maneuvers to prevent it.”

The doctors recommend a change that could have an even bigger effect: creating a committee to review newly approved cancer drugs and propose a fair price based on their benefits.

“There are tons of drugs [out there] that are very expensive, but they don’t work well,” Teferri says. “There needs to be a body that does a critical assessment of a drug’s value and helps determine what the price should be based on how much it really helps. It needs to be a true, honest and transparent discussion.”

The doctors also argue that Medicare should be allowed to negotiate drug prices.

Unlike private insurance, current law prohibits the government-sponsored insurance program from negotiating the cost of drugs with pharmaceutical companies. That means the government program is overcharged and pays the high prices drug companies typically set.

For its part, PhRMA, the main trade group for drug industry, wrote a response to the doctors’ commentary that said lowering drug prices would discourage innovation. The trade group also said that cancer drugs represent only one-fifth of total spending on cancer treatment.

But Leonard Saltz, an oncologist at Memorial Sloan-Kettering Cancer Center in New York, said the doctors’ proposals are on target.

“I think they, like me and many others, have a deep concern that this is a serious problem that’s interfering with access to care,” says Saltz, who co-wrote an influential New York Times editorial on cancer drug prices in 2012 that explained why Sloan-Kettering wasn’t using a new, more expensive medicine for colorectal cancer. Saltz didn’t take part in the latest commentary.

But can a group of doctors voicing their concerns in a journal article really change anything? “This is going to be a very difficult issue to resolve,” Saltz says. “No one effort will resolve it, but any effort to engage more people in the discussion and to raise awareness will be helpful.”

Saltz adds, “Congress is the organization that’s going to be able to make a difference here.”

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If you’ve ever had hiccups in a quiet room, you know how embarrassing and completely uncontrollable they can feel. What if, instead of the hiccups, your body jerked involuntarily or you blurted out words without meaning to? That’s a rough idea of what living with Tourette syndrome can be like.

Designers of a new computer program called TicHelper hope that they will be able to help children recognize and control these impulses themselves.

People with Tourette’s perform repetitive movements or vocalizations called tics. A simple tic might be something like head jerking, eye blinking, or throat clearing, and a complex tic might involve patterns of movement or saying multiple words or phrases.

We don’t know exactly what causes Tourette’s, says Douglas Woods, a psychologist at Texas A&M University. Woods, who is also co-chair of the Tourette Association of America Medical Advisory Board, is one of the minds behind TicHelper.

Tourette’s affects more boys than girls, and symptoms usually start between ages 3-7.

A view of TicHelper.com via TicHelper.com hide caption

itoggle caption via TicHelper.com

“Sometimes kids will grow out of [Tourette’s],” Woods says. But if the wait-and-see approach isn’t working, and the tics are interfering with daily life, there are a few treatment options.

One option is medication. Woods says there are a few different antipsychotic drugs that are used to manage Tourette syndrome, but they have side effects and don’t always work. An alternative to pharmaceutical treatment is behavioral therapy.

A form of behavioral therapy called comprehensive behavioral intervention for tics, or CBIT for short, is commonly used. CBIT training teaches people with Tourette’s to recognize the onset of a tic and to perform a different behavior when they feel one coming on.

“The idea is that when someone has a tic, they tend to have an urge,” says clinical psychologist Eric Storch, a professor at the University of South Florida and Clinical Director of Pediatrics at Rogers Memorial Hospital in Tampa. “It’s like when you’re about to yawn. You know just before it happens that a yawn’s coming. [CBIT] teaches a person to be aware.”

And it gives them the tools to manage tics. Storch describes a patient whose tic was rubbing two fingers together, to the point of rubbing off skin. With CBIT, the boy was able to recognize the onset of a tic and instead unobtrusively press down on his kneecap until the urge went away.

A typical CBIT training program involves eight sessions with a therapist, spread over 10 weeks. Results, Woods says, can be maintained up to six months.

Both psychologists say that CBIT is at least as effective as medical treatments. The problem is that it requires specially trained therapists — and there aren’t that many of them. Which is where TicHelper comes in.

“It’s essentially a self-help, self-guided program that leads the patient through a CBIT treatment,” Woods says. He and his colleagues received funding from the National Institute of Mental Health to develop TicHelper, which is now being tested. So far, the results look promising. “The kids that go through it, enjoy it,” Woods says. They’re able to do the skills,”

The program has four main sections: tic education, reducing tic triggers, tic awareness and tic blocking. Videos featuring a friendly actress guide patients thorough each section. The program personalizes treatment based on feedback from the patient. Woods says the testing will help the designers modify and improve it based on user feedback. Though TicHelper isn’t available yet, interested patients or doctors can sign up to receive updates on its progress.

The website currently lists the cost of an 8-week program through TicHelper at $150, but Woods says that the price isn’t set.

Storch, who is unaffiliated with TicHelper, is enthusiastic about the idea of at-home treatment for tics. “I really think it’s an exciting development that has a lot of practicality,” he says. “We know what behavioral treatments work well for tics, but the dissemination is really terrible.”

Storch says the biggest advantage of TicHelper will be its accessibility. CBIT, he says, works well and is incredibly safe compared with pharmaceuticals. TicHelper would maximize the benefits of CBIT by making it more inexpensive and easier to get to than therapy.

Which is not to say that Storch or Woods would recommend TicHelper as the only form of tic management. Both psychologists suggest that this program might work best as part of a management plan. One option, Woods says, might be to start treatment with TicHelper at first diagnosis and proceed to more intensive care if in-home treatment isn’t working.

Storch thinks that ideally the patient would work with the program, but touch base periodically with an experienced therapist or health care provider to check progress. But, he says, “we don’t have enough providers.” And some treatment, he says, is better than no treatment at all.

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Susan Cahill, owner of All Families Healthcare, stands in front of the first building where she opened her practice. Missoula is now the nearest place for women in the Flathead to find abortion services. Corin Cates-Carney/MTPR hide caption

itoggle caption Corin Cates-Carney/MTPR

There has never been a welcome mat for abortion service providers in the Flathead Valley, a vast county that stretches over 5,000 square miles in the Northwest corner of Montana. Susan Cahill began providing abortions in 1976 in the first clinic to offer the service in the Flathead.

“But that had an arson fire, and then we rebuilt that,” she says. “Then we had the anti-choice people try to arrest me for doing abortions when I wasn’t a doctor.”

Cahill performed abortions as a physician assistant for 38 years. Police testified in a recent trial that in March of 2014, Zachary Klundt took a hammer to the photos in Cahill’s office, poured iodine on the floor and tossed files from cabinets. Klundt damaged the building’s heating and plumbing and discharged a fire extinguisher. He said he broke into the clinic looking for prescription drugs.

Everything was destroyed in Cahill’s clinic.

“I’ve worked since I was 17,” she says. “Everything I’ve had, I’ve worked for.”

The clinic was in Kalispell, population 20,000. It’s the hub of the Flathead Valley, and the largest employer is Kalispell Regional Medical Center. In a town full of health care professionals, Cahill was the only one providing abortions.

“Because I was the only one, I got targeted,” she says.

Cahill’s clinic was a general family practice; her patients have had to find other health care. For abortion care, the options are more limited.

According to the Guttmacher Institute, in 2008 about a third of American women seeking access to abortion services traveled more than 25 miles to get them. Today, a woman in Kalispell has to drive 120 miles — each way — to Missoula to get an abortion. And some women are doing just that, says Melissa Barcroft, of Planned Parenthood of Montana, in Missoula.

“Anytime a provider stops providing services, the need doesn’t go away,” Barcroft says. “Patients still need that care.”

The loss of Cahill’s clinic has been frustrating, Barcroft says.

“I know from talking with our providers that we have seen a definite increase of patients from the Flathead area,” she says.

Cahill says she worries most about poor women, or those from the town of Browning, on the Blackfeet Indian reservation.

“The disadvantaged are always the ones that lose,” Cahill says. “Now you’ve got people who are on Medicaid, or who are from Browning, and are teenagers.” It can be much harder for them to get to Missoula, she says. “I used to give gas money for people to go home. Now … it is just a harder struggle for them.”

Cahill says plenty of local physicians can perform abortions, but they’re afraid.

Samantha Avery trained under Cahill at All Families Healthcare. At the time, Avery thought about going to medical school to pursue a career like Cahill’s.

“I know that she wanted me to be the one to take over her clinic,” Avery says. “End even before all of this, I told her, ‘I just don’t know if I could do that to my family — my future family. I can’t be the Susan Cahill. I’m not that brave of a person.’ “

Zachary Klundt and his sister in court. Corin Cates-Carney/MTPR hide caption

itoggle caption Corin Cates-Carney/MTPR

Avery decided instead to work for the Public Health Department in Flathead County. She says it was hard for her to watch Cahill lose everything so quickly. The weight of the community’s opposition to abortion is difficult to counter, she says — citing Zachary Klundt, who was convicted in the attack against the clinic, as just one example.

Klundt’s mother was on the board of Hope Pregnancy Ministries, which advocates for alternatives to abortion. She resigned after the attack.

Michelle Reimer, the executive director of Hope Pregnancy Ministries, says that what happened to Cahill and her clinic was terrible, and totally against her group’s mission.

“There is not a place for it in a Christian organization,” Reimer says. “There is always going to be the outlier, the one who represents us poorly, or who says the wrong thing, or — as we all would with a very volatile topic like abortion — expresses [himself or herself] passionately rather than logically. And I think we see that on both sides.”

Reimer says at the core of her faith is compassion — and telling a woman that regardless of what she chooses, she is loved.

In June, Klundt was sentenced to 20 years, with 15 years of that suspended. He was also ordered to pay restitution. In the courtroom, Klundt read Cahill an apology.

“I cannot even believe I did that to another soul,” he says. “But I did that to you. I know what it’s like to live with fear, and for me to do that to you is awful. And I am truly so sorry.”

He said his actions do not represent his faith.

For women in the Flathead Valley, Susan Cahill says, getting reproductive care is not any easier now that Klundt is sentenced. Her clinic is still gone.

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This story is part of NPR’s reporting partnership with Montana Public Radio and Kaiser Health News.

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About 7.5 million Americans paid an average penalty of $200 for not having health insurance in 2014 — the first year most Americans were required to have coverage under the Affordable Care Act, the Internal Revenue Service said Tuesday.

By contrast, taxpayers filing three-quarters of the 102 million returns received by the IRS so far this year checked a box indicating they had qualifying insurance coverage all year.

Counting another 7 million dependents who weren’t required to report their coverage but also filed returns, the proportion with qualifying insurance rises to 81 percent, the IRS said.

The government had estimated in January that from 3 million to 6 million households would have to pay a penalty: 1 percent of their annual income or $95 per adult in 2014, whichever is greater.

Final figures for the tax year aren’t available yet. The IRS has so far processed about 135 million of the estimated 150 million returns expected. IRS Commissioner John Koskinen said the agency was reporting preliminary figures because it has received “numerous requests” from members of Congress.

In addition to penalty totals, the IRS reported Tuesday on tax subsidies the health law provided for people who were buying coverage through the state or federal online exchanges and who qualified based on income. People had a choice of filing for credits in advance — money the government paid to their insurers — or when filing tax returns.

About 2.7 million taxpayers claimed approximately $9 billion in subsidies, reporting an average subsidy of $3,400. About 40 percent claimed less than $2,000, 40 percent claimed $2,000 to $5,000, and 20 percent claimed $5,000 or more.

Among taxpayers who claimed a subsidy, about 1.6 million, or half of taxpayers who claimed or received a subsidy, had to pay money back to the government because their actual income was higher than projected when they applied for the subsidy. The average amount repaid was about $800.

When looking at the individual mandate, the report said the vast majority of people automatically satisfied the individual mandate because they were insured last year. Another 12 million had exemptions, including people whose incomes were too low and Native Americans.

In all, the IRS said it has collected $1.5 billion from the individual mandate penalty included in the health law. About 40 percent of taxpayers who paid a penalty paid less than $100.

About 300,000 taxpayers who made an individual mandate penalty payment should have claimed an exemption but did not, the government said. The agency is sending letters to these taxpayers telling them they generally have three years to file an amended tax return.

More than 5 million taxpayers did not check the box on their tax form saying had coverage, claim a health care coverage exemption, or pay a penalty. “We are analyzing these cases to determine their status,” the government said.

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Steve Heller has worked for Minnesota’s John Henry Foster company for 15 years. He says he likes the greater choice of health plans he now has because of the private exchange. Mark Zdechlik/MPR hide caption

itoggle caption Mark Zdechlik/MPR

Until recently, John Henry Foster, an equipment distribution firm based in Eagan, Minn., offered its employees only a couple of health plans to choose from. That’s common in companies across the United States.

“They just presented what we got,” says Steve Heller, a forklift operator who has worked at John Henry Foster for 15 years.

But these days the company’s employees have dozens of choices. And something else is new: Each worker now receives money from the company (from $350 to $1,000 a month, depending on whether Heller and his co-workers are buying insurance for a single person, a couple or a family) to buy a health plan.

Employees are then directed to an online exchange — a private, secure website that offers the selection of plans for side-by-side comparison. Workers can choose high-deductible plans with relatively low monthly premiums or they can pay more each month to have more of their care and medications covered.

Just as before, the company determines the insurance companies listed, and the scope of the treatments and procedures covered by each plan.

Three years after the switch, Heller says he’s happy with his insurance and the exchange. The company’s managers are happy with it, too.

In 2012, the company was facing a big increase — 30 percent — in its costs for employee medical benefits. “Unlike anything we had ever seen before,” says Jan Hawkins, co-owner of John Henry Foster.

Jan Hawkins, one of the co-owners of the equipment distribution firm John Henry Foster, says going to a private exchange has given the company much more flexibility in budgeting for health care costs. Mark Zdechlik/MPR hide caption

itoggle caption Mark Zdechlik/MPR

So, Hawkins says, company leaders decided to sign up for a private exchange run by Medica, a Minnesota insurer, because they could choose to spend only about 10 percent more on health benefits in the first year, instead of that 30 percent increase projected under the old plan.

Since then, the firm has increased the money it gives employees to spend on health insurance by roughly 10 percent each year.

“I think it definitely helps us from an operational budget standpoint,” Hawkins says. “We’ve just seen only positives from this.”

Despite the benefits to a company’s bottom line, and more choices for employees, John Henry Foster is one of relatively few businesses using a private health insurance exchange. According to research by the Kaiser Family Foundation, last year only 3 percent of employers (excluding the federal government) insure their employees this way.

But it’s a trend that some experts expect to pick up steam soon. “I would say a majority of the companies will switch to private exchanges,” says Dr. Jim Bonnette, with the health care consulting firm The Advisory Board Co.

Bonnette thinks that employees under this sort of system are likely to choose high-deductible plans and be much more motivated than in the past to search out the best value for care. That could finally force consumers to pay attention to the price of health care, he says, a goal that has eluded health policymakers for decades.

“We can’t afford the trend — that is, the increase in cost per year — that we currently have,” Bonnette says. “So how do you get people to think differently about how they receive care and what it costs?”

But shopping wisely for health care is almost impossible says Sara Collins from the Commonwealth Fund, a health policy research organization.

It’s often difficult for consumers to find out how much a doctor visit or a particular procedure costs. And, Collins says, studies show that people with high-deductible plans often forgo care to save money; they’ll even avoid free preventive care because they don’t understand how their health insurance works.

“The idea that people who have such low understanding of what is included or excluded in their deductible can actually go out and price-shop for their health services, I think, really stretches the imagination,” she says.

Kim Wagner, a benefits consultant, says predictions of a big shift to private exchanges are overblown. Although some employers are adding more health plan choices for workers, she says, giving employees a set amount to buy insurance on an exchange could alienate workers and increase turnover.

The practice of giving employees a limited amount of money to purchase their own insurance has been around for a while, Wagner says, but “hasn’t taken off, particularly in the large employer space, because truly it’s a cost shift.”

Workers suddenly asked to shoulder more of the cost of their health care may be more likely to look for a job elsewhere — opting for companies that offer better benefits.

Nonetheless, firms that now use generous benefits as a selling point to lure top talent may soon be more motivated to set up these sorts of private insurance exchanges, too. Beginning in 2018, companies that offer health insurance packages the government deems too generous will start having to pay a 40 percent tax on those packages.

It’s called the “Cadillac” tax (meant to reduce health spending by discouraging luxurious health plans), but it is not as exclusive as its name implies. Towers Watson, a consulting firm, predicts that 48 percent of employers will have to pay the tax in its first year.

This story is part of NPR’s reporting partnership with Minnesota Public Radio and Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

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It’s a situation that occurs all too often: Someone goes to the emergency room and doesn’t learn until he gets a hefty bill that one of the doctors who treated him wasn’t in his insurance network. Or a diligent consumer checks before scheduling surgery to make sure that the hospital she plans to use and the doctors who will perform the operation are all in her network. Then she learns later that an assistant surgeon she didn’t know — and who wasn’t in her network — scrubbed in on her operation, and charged her for it.

“If we’re mandating that people buy insurance coverage it seems we should also protect them from surprise medical bills,” says Mark Rukavina, founder of Community Health Advisors in Chestnut Hill, Mass.

If an out-of-network doctor or other provider doesn’t have a contract with a health plan that determines how much they get paid for services, they may bill the patient for any charges not covered by insurance. In those instances, the consumer could be on the hook for the rest of the bill, a practice known as balance billing.

Although there’s no federal restriction, about a quarter of states have laws on the books against balance billing by out-of-network hospitals, doctors or other providers, in at least certain circumstances such as emergency care.

New York recently took that sort of action. The state’s law, which became effective for coverage that renewed after March 31, significantly expands consumer protections, and may be the most comprehensive legislation of its type, says Jack Hoadley, a research professor at Georgetown University’s Health Policy Institute.

“If the pieces work like they set them up to, it feels like they’ve got all the bases covered,” says Hoadley, who recently coauthored a study that examined protections in seven states against balance billing.

Under the New York law, patients are generally protected from owing more than their in-network copayment, coinsurance or deductible on bills they receive for out-of-network emergency services or on surprise bills.

A bill is considered a surprise if, for example, patients at a hospital or ambulatory surgical center that’s in their network receive services from a doctor who, without their knowledge, is out-of-network. In addition, if consumers are referred to out-of-network providers but don’t sign a written consent form saying they understand the services will be out-of-network and may result in higher out-of-pocket costs, it’s considered a surprise bill.

“A key element that is really new is that for anyone who gets a surprise out-of-network service, or who doesn’t get the right disclosure [beforehand] about it, there’s a way for the consumer to step out of the middle of the transaction,” says Mark Scherzer, legislative counsel for New Yorkers for Accessible Health Coverage, an advocacy group for people with chronic illnesses and disabilities.

Under the New York law, to get relief from a surprise bill a consumer first needs to complete an “assignment of benefits” form that allows the provider to pursue payment from the health plan. The patient then sends the form and the bill to her insurer and to the provider. As long as she’s taken that step, she won’t be responsible for any charges beyond her regular in-network cost sharing.

“Consumers basically say to the doctor or the hospital, ‘I’m giving you my rights to reimbursement; you can duke it out with the insurance company,’ ” Scherzer says.

In situations involving out-of-network emergency care, patients should inform the insurance company if they receive a bill. The insurer will take it from there.

The law also sets up an independent dispute resolution process for providers and health insurers to settle disputes that arise regarding emergency services or surprise bills.

It’s too soon to say how well the law will work, but consumers are already calling the hotline of the Community Service Society of New York to find out if they’re eligible, says Elisabeth Benjamin, vice president of health initiatives there.

“So many times people just give up,” Benjamin says. With the new law, they may not have to.

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After nearly 30 years, the Obama administration wants to modernize the rules nursing homes must follow to qualify for Medicare and Medicaid payments.

The hundreds of pages of proposed changes cover everything from meal times to use of antipsychotic drugs to staffing. Some are required by the Affordable Care Act and other recent federal laws, as well as the president’s executive order directing agencies to simplify regulations and minimize the costs of compliance.

“Today’s measures set high standards for quality and safety in nursing homes and long-term care facilities,” Health and Human Services Secretary Sylvia Burwell said in a statement. “When a family makes the decision for a loved one to be placed in a nursing home or long-term care facility, they need to know that their loved one’s health and safety are priorities.”

Officials unveiled the update as the White House Conference on Aging convenes Monday. The once-a-decade conclave sets the agenda for meeting the diverse needs of older Americans, including long-term care options. This month also marks the 50th anniversary of the Medicare and Medicaid programs, which cover almost 125 million older, disabled or low-income Americans. Medicare and Medicaid beneficiaries make up the majority of residents in the country’s more than 15,000 long-term care facilities.

“The existing regulations don’t even conceive of electronic communications the way they exist today,” said Dr. Shari Ling, Medicare’s deputy chief medical officer. “Also there have been significant advances in the science and delivery of health care that just weren’t imagined at the time the rules were originally written. For example, the risks of antipsychotic medications and overuse of antibiotics are now clearly known, when previously they were thought to be harmless.”

The proposed regulations include a section on electronic health records and measures to better ensure that patients or their families are involved in care planning and in the discharge process. The rules also would strengthen infection control, minimize the use of antibiotic and antipsychotic drugs and reduce hospital readmissions.

Revised rules would also promote more individualized care and help make nursing homes feel more like home. For example, facilities would be required to provide “suitable and nourishing alternative meals and snacks for residents who want to eat at non-traditional times or outside of scheduled meal times.”

Residents should also be able to choose their roommates. “Nursing facilities not only provide medical care, but may also serve as a resident’s home,” the proposed rules say. “Our proposed provision would provide for a rooming arrangement that could include a same-sex couple, siblings, other relatives, long term friends or any other combination” as long as nursing home administrators “can reasonably accommodate the arrangement.”

Consumer advocates are likely to be disappointed that officials are not including recommendations to set a federal nurse-to-resident ratio.

However, the proposed changes would require that nurses be trained in dementia care and preventing elder abuse to better meet residents’ needs.

“We believe that the focus should be on the skill sets and specific competencies of assigned staff,” officials wrote in the proposed rules, “to provide the nursing care a resident needs rather than a static number of staff or hours of nursing care that does not consider resident characteristics.”

Nursing homes will be required to report staffing levels, which Medicare officials said they will review for adequacy.

“It’s a competency approach that goes beyond a game of numbers,” said Ling. “If residents appear agitated, figure out why, get at the cause of the problem,” she said, instead of resorting to drugs to sedate residents.

Advocates for nursing home residents argue that because of inadequate staffing, residents with dementia are often inappropriately given antipsychotic drugs, even though that can be dangerous for them. The new rules would help control the use of these drugs by requiring the facility’s pharmacist to monitor drugs that are prescribed for excessive periods of time or other irregularities and require the resident’s physician to address the problem or explain in the resident’s medical record why the medication is necessary.

“We don’t have enough nursing staff,” Toby Edelman, a senior policy attorney at the Center for Medicare Advocacy, said before the rules were released. Federal law requires only one registered nurse on the day shift for a 20-bed facility or as much as a 500-bed facility, licensed practical nurses around the clock and sufficient staff to meet residents’ needs, she said.

“We don’t look at the specific staffing positions per se,” said Greg Crist, a spokesman for the American Health Care Association, which represents 11,000 skilled nursing facilities. “We look at the needs of the individuals when determining staff levels, and that is best addressed in the resident’s care plan.”

Although there are also no provisions addressing enforcement in the proposed rule, Ling said it “will permit detection of violations to enable enforcement by lessening the noise.”

“The biggest problem is that the rules we have now are not enforced,” said Edelman. “We have a very weak and timid enforcement system that does everything it can to cajole facilities into compliance instead of imposing penalties for noncompliance.”

A report by the Center for Medicare Advocacy last year found that some serious violations often were not penalized.

“Once the new rules are finalized, they will be added to the items nursing home inspectors check,” Ling said.

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