Posts Tagged ‘Government Accountability Office’

The Patient Self Determination Act and Trends in Advance Directives

MAY 4, 2015 VOLUME 22 NUMBER 17

Last month the U.S. Government Accountability Office released a short report on the use of advance directives in hospitals, nursing homes and other health care facilities. The report, requested by members of the Senate Committee on Commerce, Science, and Transportation, addressed the experience with health care powers of attorney, living wills and other advance directives. It makes interesting reading — or at least it is interesting to policy wonks concerned about individual autonomy and self-determination.

To review: the federal Patient Self Determination Act was adopted in 1990. It requires each state to summarize its state laws on advance directives (and to make that summary publicly available). It also requires hospitals, nursing homes, hospices, home health agencies, health maintenance organizations, and Medicare Advantage providers to inform patients about advance directives and to ask if they understand the concepts. It does not explicitly require health care providers to either ask for advance directives or to require any patients to complete them (in fact, the law prohibits any provider from requiring advance directives), but the thinking when the law was passed was that advance directives would become much more common.

Although the federal law does not require it, many states responded by not only summarizing their laws but also providing simple forms for patients to complete. And, though the law does not require this step either, many health care providers responded by offering those simplified forms to patients on admission or periodic review.

How well has the federal law worked in its quarter-century of existence? The study doesn’t really answer that question, though it does give some data points to assess changes in the medical community and care standards. At the time of adoption of the Patient Self Determination Act, activists estimated that perhaps 20% of patients had executed an advance directive. The study finds that almost half of adults over age 40 have now signed a living will or health care power of attorney. That suggests that something more than twice as many patients have done at least some health care planning — though it is unclear whether that is the result of the federal law or changing public knowledge and preferences (or both things).

Perhaps more interestingly, the study found wide disparities by type of care facility, medical condition, age, race, income level, and education level. Even gender made a significant difference, with women signing advance directives about 5% more frequently than men.

Interestingly, though, only a handful of the demographic categories reviewed in the GAO report had more than 50% compliance. Nursing home residents had signed advance directives about 55% of the time (up 10% from the previous decade). 60-year-olds had perhaps the most vigorous increase in signature rates, moving from just under half having signed a decade ago to almost three out of four today.

Interested in some of the other categories? You can read the report yourself, as it is available online. But here are some of the more interesting items we extracted from its analysis:

  • Unsurprisingly, people with chronic illness are about 10% more likely to have signed an advance directive. We say “unsurprisingly,” but perhaps it is surprising that the gap is not even wider, since only about one-third of those with chronic illness have signed.
  • People over age 65 are about twice as likely to have signed advance directives as their younger relatives. Adults under age 35 weigh in at only about 10%.
  • “White” Americans are much more likely to have signed advance directives than are African-Americans, Latinos or other races or ethnic groups. (Why quotation marks around “white”? Well, wouldn’t “pink” be more accurate?)
  • There is a clear relationship between income (each $25,000 increase in annual income seems to correspond with a 3-5% increase in signatures) and education (each degree increases the signature rate by at least 5%).

What does this information suggest to us about the use of advance directives? We have a number of ideas — occasioned more by our real-world experience than empirical evidence:

  1. You could sign an advance directive, right now. If you live in Arizona, there are plenty of resources to make it easy. Want to find Arizona forms? The Arizona Attorney General’s office has had perfectly acceptable forms online for several decades. Over time the detail, and the explanation, has grown the file to more than 20 pages — but don’t be intimidated. Actually filling out and signing the forms is pretty straightforward, and you could complete it today. Based on the statistics in the GAO report, there’s about a 50% likelihood that you’ll increase the percentage of coverage (that is, there’s about an even chance you haven’t done this yet).
  2. Do you already have an advance directive? No? Are you sure? We’re surprised how often long-time clients come back to see us to update their estate plans, and, “oh, by the way, I need to sign one of those health care powers of attorney this time.” Clients are often surprised that they’ve had perfectly good advance directives for years. If you’ve met with a lawyer any time in the past thirty years, you probably have gotten advance directives with your other estate planning documents.
  3. Sometimes people vaguely recall signing a health care power of attorney or a living will, but can’t think of where the documents are now. Wouldn’t it be nice if there was an easy way to keep these documents available online, and maybe just carry a wallet card with the information (for emergencies)? Good news! You can do exactly that — at least if you live in Arizona. We are one of about a dozen states operating a state registry for advance directives; it’s easy, free and helps keep track of your documents.

 

Government Report Highlights Problems With Older Drivers

APRIL 30, 2007  VOLUME 14, NUMBER 44

Several times over the past few years (most recently in Safety for the Older Driver: Is Skills Training the Answer?) we have reported on an issue of great concern to seniors—the effect of aging on the ability to drive. Now Congress has gotten interested in the topic, if a recent report from the Government Accountability Office (GAO) (“Older Driver Safety: Knowledge Sharing Should Help States Prepare for Increase in Older Driver Population“) is any indication.

Senators Herb Kohl (D-WI) and Gordon Smith (R-OR), the Chairman and ranking minority member, respectively, of the Senate Special Committee on Aging, requested a review of state laws governing older drivers. The report details some of the reasons for concern, including:

  • Older drivers are less likely than their younger counterparts to be involved in fatal automobile accidents. However, if the results are recalculated based on number of miles driven older drivers perform much more poorly. Those aged 75 or older have a fatal accident rate higher than the next-highest category, drivers aged 16-24. Those two groups both suffer considerably more than double the fatal accident rate of any other age group.
  • The number of older drivers on the road is, of course, increasing more quickly than other age groups. With the aging of our population, problems associated with age and driving are expected to increase steadily.
  • Older drivers experience a particularly higher accident rate in intersections. More than half of all fatal accidents involving drivers over age 85 occur in intersections. While 37% of all fatal accidents involving drivers over age 65 occur at intersections, for drivers aged 26 to 64 the comparable figure is only 18%.

“Navigating through intersections,” notes the report, “requires the ability to make rapid decisions, react quickly, and accurately judge speed and distance.” What can be done to reduce intersection risk for older drivers? The report details a number of design ideas which might be implemented, including signage well in advance of intersections, larger street name and stop signs, black signal backplates (to make traffic signals more visible to older drivers), and offset turn lanes (to make it easier to see oncoming traffic).

The report also details regulatory steps taken by a handful of states to help ease drivers off the roads when they are impaired as part of their aging. Sixteen states require older drivers to renew their licenses more frequently. Arizona driver’s licenses, for instance, do not require renewal at all until age 65, and then require renewal every five years. Ten states (including Arizona) require older drivers to pass vision tests. Five states require older drivers to renew their licenses in person, rather than by mail (Arizona is one of those states, as well, requiring in-person renewals after age 70).

GAO Report Criticizes Lax Oversight of Nursing Homes

APRIL 23, 2007  VOLUME 14, NUMBER 43

Individuals with disabilities, confused and vulnerable seniors and patients recovering from medical procedures often end up staying in nursing homes for weeks, months or years. Quality of care in those facilities is obviously important, and yet difficult to monitor. The good news: since most nursing homes accept Medicare and/or Medicaid dollars, they are subject to close scrutiny and, when they fall below basic levels of care, to penalties that can force them to improve. The bad news: the government agency charged with conducting that scrutiny does an inadequate job.

You won’t have to take our word for it. The Government Accountability Office (formerly the General Accounting Office, but better known as the GAO) is Congress’ investigative arm, and is famous for its non-partisan reviews of government programs. In a report finalized last month and issued to the public today, the GAO takes the government to task for its failure to impose meaningful sanctions on nursing homes that repeatedly harm residents.

The federal agency charged with monitoring nursing home compliance has a spotty track record of enforcement. The GAO report found that sanctions were too often delayed, and often voided altogether when the offending home submitted a plan for compliance. That practice did not change, notes the GAO, even for homes with multiple offenses.

The 63 homes (in four states) surveyed by the GAO, for example, had a total of 444 citations for deficiencies that actually harmed residents. It is important to note that those citations were not complaints—presumably there were many more complaints filed—but actual findings of deficiencies, and that those deficiencies resulted in actual harm to patients. So how many of those resulted in immediate sanctions? Just 69, or a little more than 15%.

Although given authority to impose fines as high as $3,000 per day against offending nursing homes, CMS (The Centers for Medicare and Medicaid Services) imposed fines of $350 to $500 per day, and those fines were not collected until the expiration of an appeal process that might take years in a given case. More than half the time CMS chose sanctions that gave the nursing homes another three months to correct deficiencies rather than the fifteen-day option available to the agency. In almost a quarter of cases meriting immediate sanctions, there was no evidence of any action being taken at all.

What did CMS say in response to the criticism? The agency “is taking additional steps to improve nursing home enforcement … but it is not clear whether or when these initiatives will address the enforcement weaknesses GAO found.”

The entire report, “Nursing Homes: Efforts to Strengthen Federal Enforcement Have Not Deterred Some Homes from Repeatedly Harming Residents,” is available online. An abstract highlights the report’s major findings.

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