Only 16% Medi-Cal recipients estimated to be eligible for Community-Based Adult Services were served by the program in 2020.
Two Medi-Cal long-term care programs designed to keep seniors and disabled adults out of nursing homes are serving only a fraction of the eligible population, a UCLA Center for Health Policy Research study finds.
The study found high potential demand across the state for services offered by Medi-Cal's Multipurpose Senior Services Program, which provides health and social services for people 65 and older who would otherwise require institutional care, and Community-Based Adult Services, which provide professional care at licensed adult day health centers in the community for disabled people and others at risk of institutionalization.
However, only about 39,000, or 16%, of the roughly 243,400 Medi-Cal recipients estimated to be eligible for Community-Based Adult Services were served by the program in 2020, the study found.
Demand will only grow in coming years, with the need for such services increasing through 2025 and 2030 and into 2050, when people 65 and older are expected to make up some 25% of California's population, according to the study.
"Supportive programs provided to older adults and adults with disabilities at home and in the community are essential to maintaining physical and mental health," says Kathryn Kietzman, director of the center's Health Equity Program. "As the state continues to implement its Master Plan for Aging, it is critical that gaps in access to long-term services and supports are addressed."
The researchers also found wide disparities by race and ethnicity, age, and geography in the proportion of people estimated to be eligible and those currently receiving these long-term services and support.
Among the study's findings:
106,700 people were estimated to be eligible for the Multipurpose Senior Services Program in 2020 — almost 10 times more than the 10,324 people served.
Among those estimated to be eligible for Community-Based Adult Services, Black Americans and those who identified as two or more races were among the least likely to be receiving services, at 4% and 5%, respectively.
Older Asian and Black adults were among the groups most underserved by the Multipurpose Senior Services Program.
All of California's geographic regions had significantly more people who were potentially eligible for both Community-Based Adult Services and the Multipurpose Senior Services Program than actually used them.
Los Angeles County served 38% of those potentially eligible for Community-Based Adult Services in 2020, while other Southern California regions, taken together, served 10%.
The lowest rates of participation in Community-Based Adult Services were seen in the Northern and Sierra region (2%) and the San Joaquin Valley (3%).
The greatest participation in the Multipurpose Senior Services Program was observed in the Northern and Sierra (65%) and Central Coast (38%) regions.
"Our hope is that these findings will inform and prioritize the implementation of strategies to increase access to care," Kietzman says. "Ideally, program planners and providers will find ways to improve communication about available programs, ease pathways to program information and enrollment, and streamline eligibility requirements."
Violators could get booted from the prestigious Boston hospital.
With violence against healthcare workers reaching epic proportions, Mass General Brigham Hospital has launched a campaign to curb abuse from patients and visitors.
Under a newly imposed Patient Code of Conduct, patients and visitors who disrupt care, make verbal or physical threats -- including racist, sexist, discriminatory or disrespectful comments about clinicians, other hospital staff, other patients and visitors -- could face a verbal reprimand, and even expulsion from the Boston hospital and possible suspension of future care access.
"Just as we expect all of our employees and clinicians to treat each other and every patient and visitor with courtesy and respect, we have the same expectations of all of you," Allison Bryant, MD, Mass General Brigham's senior medical director for health equity, says in a YouTube video on the health system's website.
"If there is a time where your actions violate the code, our staff will remind you of the expectations," Bryant says. "Depending on the situation, it is possible that family members or visitors who violate the code may be asked to leave the premises and future visitations may be restricted."
"If necessary patients who repeatedly act in disrespectful or discriminatory ways may be asked to make other arrangements for their care and obtaining future non-emergency care at MGB site may require review."
Mass General Brigham says it created the patient code of conduct in response to the alarming increases in violence and hostility directed against hospital staff across the nation, including encounters that have resulted in the deaths and harassment of clinicians.
In January, two dozen Neo-Nazis held a protest in front of Brigham and Women's Hospital and targeted for harassment two physician-advocates for health equity. In 2015, a Brigham cardiac surgeon was murdered by an angry patient.
A Bureau of Labor Statistics report found that injuries from violent attacks against medical professionals grew by 63% from 2011 to 2018. Hospital officials say the problem has intensified since the COVID-19 pandemic. A National Nurses United survey of more than 2,500 nurses in April found that nearly half (48%) reported an uptick in workplace violence – up from 22% in March 2021, a 119% increase.
"We are now more than three years into the pandemic and not only is staffing worse, but workplace violence is increasing," NNU President Zenei Triunfo-Cortez, RN, says. "Nurses are experiencing alarming levels of moral distress and moral injury due to the unsafe working conditions. Since our last survey in September 2021, even more nurses have reported feeling more stress and anxiety as well as feeling traumatized by their experiences caring for patients."
The threat of violence is one of several factors that are driving burned-out nurses from the profession, including chronic understaffing, an inability to manage surge capacity, and continued shortages of personal protection equipment, Triunfo-Cortez says.
Massachusetts Nurses Association President Katie Murphy, RN, says her union is "generally supportive of the new code of conduct, in the sense that we agree with the direction and goal of the policy and policies like it, but we may even want employers and the state to go further in some instances."
"We have pending workplace violence protection legislation for that purpose, which would require each MA healthcare facility to work with its staff to create threat/violence protections unique to its environment."
Murphy put some of the blame on the nation's healthcare delivery system, saying "we must also acknowledge that patients and healthcare workers are under tremendous stress created by a system that too often values profits at the expense of local services, safe staffing, and quality care."
"With healthcare violence rising during the pandemic, it is more important than ever that employers upgrade their policies in collaboration with nurses and other caregivers," Murphy says.
Proponents of the expansion says the expense to the state is justified financially.
More than a quarter-million undocumented income-eligible adults age 50 and older in California are enrolled in Medi-Cal, as a result of Gov. Gavin Newsom’s 2021 initiative to expand the healthcare access regardless of immigration status, the California Department of Health Services has announced.
"We’re making sure that universal access to healthcare coverage becomes a reality here in California, and this expansion has gotten us one step closer – more than a quarter million undocumented Californians aged 50 and older now have good, quality health care," Newsom says.
DHCS implemented the older adult expansion to provide state-funded full scope Medi-Cal to people 50 years of age or older who are ineligible for federally-funded full scope Medi-Cal because of their immigration status. This includes those who were enrolled in restricted scope Medi-Cal before implementation of the older adult expansion on May 1.
Proponents of the expansion says the expense to the state is justified financially, because people who have access to preventive services and regular healthcare and home-based care tend to stay healthier, and out of emergency rooms and nursing homes.
In May 2016, children under 19 years of age became eligible for full scope Medi-Cal benefits, and in January 2020, full scope Medi-Cal was extended to young adults ages 19 through 25, regardless of immigration status.
Starting January 1, 2024, Newsom’s Healthy California for All initiative will expand full scope Medi-Cal coverage to more than 700,000 undocumented adults ages 26 through 49 who are ineligible for federally funded Medi-Cal.
The California Department of Health Care Services agrees with the audit findings.
Federal watchdogs are asking Medi-Cal to refund $15.7 million in unallowable capitation payments made to managed care organizations on behalf of beneficiaries with multiple Client Index Numbers.
The U.S. Department of Health and Human Services Office of the Inspector General audited $112.1 million ($56.1 million federal share) in Medi-Cal capitation payments made to MCOs from July 1, 2015, through June 30, 2019, for 12,686 beneficiary matches.
Based on a random sample of 100 beneficiaries, OIG found that Medi-Cal made improper capitation payments in 76 cases totaling $657,057 ($328,529 federal share).
"On the basis of our sample results, we estimated that California made unallowable capitation payments totaling approximately $31.4 million ($15.7 million Federal share) on behalf of beneficiaries with multiple CINs during our audit period," OIG says.
The California Department of Health Care Services agrees with the audit findings, attributes the improper payments to "human error" at the county level, and says it is implementing a correction plan.
"Specifically, during the file clearance process, California county staff made data entry errors that included misspelling beneficiaries' names," OIG says. "Also, staff transposed Social Security numbers, failed to identify and link multiple records, and did not always identify and resolve variations in beneficiaries' names."
OIG says that the algorithm that CDHS used to create the Beneficiary Name and Date of Birth Match Report was too broad and ineffective, and that CDHS did not require county staff to review training materials.
OIG recommends that CDHS: refund the $15.7 million federal share in unallowable payments, review capitation payments that fell outside the OIG audit period and refund any unallowable payments; ensure that the algorithm used to in its revised Beneficiary Name and DOB Match Reports is effective at detecting individuals with multiple records; require training for county staff to prevent issuing multiple CINs; and enhance internal controls to ensure that no beneficiary is issued multiple CINs.
The survey commissioned by Elevance Health found that convenience and accessibility were top draws for telehealth consumers.
An overwhelming majority (94%) of adults who've used telehealth to access primary care say they're satisfied with the virtual experience, which 79% say "has allowed them to take charge of their health."
The online poll of more than 5,000 people, 32% of whom say they've accessed virtual primary care, was commissioned by Elevance Health (formerly Anthem, Inc.,) and conducted in March by The Harris Poll.
The poll also found that convenience and accessibility were top draws for telehealth among consumers.
"Consumers are using digital technologies at an accelerating pace, and consistent with this, we're seeing at Elevance Health use of telehealth that is nearly 20 times greater than pre-pandemic levels," says Rajeev Ronanki, president of digital platforms at Elevance.
"Virtual primary care gives individuals the opportunity to work with innovative services that make healthcare more convenient, accessible, and fit into their increasingly busy schedules," Ronanki says. "The study's findings reiterate the desires of consumers to use digital technology – along with using traditional in-person care options – to take control of their health."
While the popularity of telehealth has grown substantially during and after the pandemic, the poll found that only 48% of respondents said they were familiar with the technology, although 73% of respondents said that virtual primary care was appealing to them, primarily for convenience (35%), accessibility (31%), and overall ease of use (30%).
For those who haven't used virtual primary care, 31% say that physicians need to see them in person to diagnose ailments, while 21% say they're not sure if telehealth is covered by their insurance and that it may cost more.
Telehealth advocates point to studies that have shown that virtual care is effective to help manage chronic conditions, such as diabetes, high blood pressure, and asthma, and for urgent minor health issues such as allergies, cold, and skin rashes.
"As we develop the future of consumer-centered healthcare, it is important that we create a digital care network that gives individuals access to a spectrum of connected services, which includes virtual primary care as well as in-office, in-home, and digital services," Ronanki says.
While 82% of Americans feel their health is excellent or good, in reality 63% are living with or managing chronic health conditions. Two-thirds (62%) of poll respondents managing chronic conditions say virtual primary care could help them take charge of their health.
The poll also found that:
People with a chronic health condition are more likely to be familiar with virtual primary care (52% vs. 42%).
41% of people with a primary healthcare doctor want to see more use of digital communication, such as text messages or emails.
52% with a primary care physician say they would use virtual primary care in addition to the care they receive from their current primary healthcare provider within the next year, while 59% are likely to do so within the next two to five years, and 62% beyond the next five years.
84% of people who have accessed virtual primary care say it has been very useful during the pandemic and that they plan to continue using it as pandemic conditions improve.
Large majorities of respondents say they want to use virtual primary care for prescription refills (76%), referrals to specialists (72%), non-urgent (67%) and/or urgent issues (58%).
71% say that the nation's care delivery system is improving with the use of telehealth.
83% say it's a great way to increase access to healthcare for people who may otherwise be unable to visit a provider in person.
The PBM lobby has called the states' push for oversight "both misplaced and irrelevant."
California Attorney General Rob Bonta has joined 35 attorneys general who've filed an amicus brief with a federal appeals court in support of Oklahoma's authority to regulate pharmacy benefit managers.
"Ensuring access to affordable and regulated prescription medication is essential to the health and well-being of Californians," Bonta says.
"The expanded power of PBMs in the pharmaceutical industry has had an outsized, negative impact on drug pricing and the availability of pharmacies in vulnerable communities. States have a responsibility to regulate PBMs to curb the rising cost of lifesaving prescription drugs."
The AGs brief, filed with the U.S. Court of Appeals for the 10th Circuit in Denver, notes that PBMs over the years have expanded into a multi-billion-dollar industry that does nothing to lower drug prices paid by health plans to drug makers.
The growth and consolidation of PBMs with major retail pharmacies like CVS and health plans such as Aetna, has resulted in below-market reimbursements for smaller, independent pharmacies that are often driven out of business, the AGs say.
In response, Oklahoma and other states have bolstered oversight of PBMs to protect consumers, who ultimately pay for the higher drug costs.
A 2021 study in Health Affairs found that the closure of neighborhood pharmacies in California disproportionately occurs in communities of color.
'Unsupported Attacks on PBMs'
The Pharmaceutical Care Management Association, the lobbying group for PBMs, has called the "unsupported attacks on PBMs…. both misplaced and irrelevant" and argued that the Oklahoma law "interferes with health plans' ability to design benefits for Oklahomans that are flexible, cost-effective, and high-quality."
"The law would increase health care costs and threaten access to prescription drugs for Oklahoma's businesses, employees, and Medicare beneficiaries," PCMA says.
"Furthermore, the core argument presented by Oklahoma and rehashed in amicus briefs filed by the independent pharmacy lobby and certain attorneys' general has been rejected in nearly every court that has considered it, including the Supreme Court."
KaufmanHall examines strategies hospitals are using to overcome chronic clinical staffing shortages.
Chronic staffing shortages and high labor costs were the biggest "pressure point" cited by scores of hospital executives across the nation in a recent survey from Kaufman Hall.
While nearly half (46%) of the 86 respondents to the management consultant’s 2022 State of Healthcare Improvement Reportsay that reducing labor costs provides the greatest opportunity for cost reductions, virtually all of the respondents (98%) say they’re bumping up starting wages, 84% are offering signing bonuses, 73% are offering retention bonuses, and 47% are paying for more overtime hours.
"The combination of staffing shortages and inflationary pressures have pushed salaries and wages up in all areas, although administrative wages have increased less dramatically than wages for support services and clinical positions," the report says. "Only 2% of respondents had seen administrative wages rise more than 10%; while 68% increased administrative wages no more than 5%."
"In contrast, 19% percent saw increases of more than 10% for support services and 67% saw increases of more than 10% for clinical staff," the report says, noting that one-third of respondents saw wage increases for clinical staff top 15% or more, which is nearly twice the 8.3% rate of inflation in August, as determined by the Consumer Price Index.
Understanding that money has to big a big part of the equation, KaufmanHall also offered six low- or no-cost efficiencies that it says can lower costs and retain staff.
Be flexible: Hospitals are designing scheduling strategies that create flexibility for staff, such as hybrid remote working arrangements.
Streamline recruiting and onboarding: Get them on board, and get them paid, ASAP. "Organizations that cannot get candidates into their new positions quickly risk losing them to faster-acting organizations.
Use automation: Robotics, artificial intelligence and other evolving technologies provide an opportunity to reduce the burden of manual administrative tasks while improving productivity and nurse satisfaction.
Strengthen mentoring programs and succession planning: Given the historically high turnover among veteran staff, it’s becoming more important to identify tomorrow’s leaders today, and hone the skills they need to thrive.
Redesign care models: Create efficiencies that eliminate redundancies and waste and that give clinicians more time to interact with patients and to perform "at the top of their license."
Use predictive analytics: Models that can forecast volume and staffing needs help align the workforce and reduce the need for overtime or temporary help. volume modeling and staffing forecasting tools.
Under the new plan, nurses can pick a role that fits their individual and professional preferences.
SSM Health has created "flexible nursing employment options" that the St. Louis-based health system says will give nurses more freedom and opportunities to shape their careers.
"We created our programs for today's caregivers to offer more options, flexibility and earning potential," says Seth Lovell, SSM Health System Vice President of Nursing.
Under the new plan, nurses can pick a role that fits their individual and professional preferences. For example, the PRN 1-3 programs let nurses work around their schedule to pick up extra shifts every month. The PRN 4 programs lets nurses become full-time travelers without missing home or experiencing the uncertainty of agency or freelance work. The Float Pool programs give nurses the chance to experience different SSM Health regions or specialties.
With healthcare enduring chronic staffing shortages, and competition for nurses growing, Lovell says SSM recognized the need to develop attractive employment options for nurses.
"RNs in a flexible nursing role qualify for pay practices that are rarely offered to that segment of the workforce, including shift differentials, critical shift bonuses, and premiums," she says. "We are proud to offer these unique programs to all SSM Health nurses."
The staggering $713.6 million spent in 2020 grew by more than 70% when compared with the $358.2 million the sector spent in 2000.
The nation's healthcare sector – including payers, providers, pharma, and health product manufacturers -- spent a combined $713.6 million to influence federal healthcare policy in 2020, a new report shows.
When compared with lobbying expenditures in 2000, the 2020 expenditures represent 70% growth across four areas of healthcare including $308.4 million from pharma and manufacturers, $287 million from providers, $80.6 million from payers, and $37.7 million by "other firms," according to the report, which was published Thursday in JAMA Health Forum.
"These findings reveal that spending from pharmaceutical and health product manufacturers and providers, including their associated trade organizations, comprise the majority of lobbying expenditures from the healthcare sector," say the report's researchers from Cornell University's Joan & Sanford I. Weill Medical College, and Penn's Perelman School of Medicine.
The spending was highly concentrated, with the top 10% of healthcare firms accountable for 70% of spending among payers and manufacturers, and 59% for providers.
"Lobbying activities also were not distributed uniformly, with a small number of firms responsible for the majority of expenditures," the report says.
Spending among the "other firms" was less concentrated, with the top 10% of donors accounting for 38% of spending.
The figures are based on healthcare sector federal lobbying records from 2000 to 2020, filed with the Senate Office for Public Records, and obtained from Open Secrets, a nonpartisan nonprofit that tracks money in politics.
The report notes that lobbying expenditures could be considerably higher because their research does not include state-level and grassroots lobbying, although the growth in spending has tapered off since the early 2000s amid efforts to influence the Affordable Care Act.
DOJ says Sutter billed government payers for urine tests performed by third-party labs.
Sutter Health and its affiliate Sutter Bay Hospitals will pay the federal government more than $13 million to resolve civil allegations that the Sacramento-based health system billed Medicare and other government payers for thousands of urine tests that were performed by third-party labs, the Department of Justice says.
Federal prosecutors say that in 2016 and 2017 Sutter Health's Alta Bates Summit Medical Center in Oakland contracted with Navigant Network Alliance, LLC, under which Navigant referred to Sutter for analysis urine toxicology specimens collected from labs and doctors across the nation, which Sutter then billed the federal government.
"The United States asserts that Sutter did not perform the quantitative testing on thousands of specimens referred under the agreement and that these quantitative tests were instead performed by third-party labs… Sutter nevertheless sought reimbursement for the tests," DOJ says, and that the health system ultimately was paid for the tests by the Federal Employees Health Benefits Program, Medicare, Medicaid, and Tricare.
"Sutter Health agreed to pay $13 million to settle allegations that it billed government health programs for lab tests performed by others," says Stephanie Hinds, US attorney for the Northern District of California. "Government healthcare programs must be protected, and this office will investigate and pursue healthcare providers that fail to provide the services paid for by public healthcare programs."
Sutter has already paid $6.5 million of the $13,091,452 settlement and will pay the remaining $6.5 million within the next 30 days.
Sutter Health declined comment when contacted by HealthLeaders.
