Posts Tagged ‘White House Conference on Aging’

Fraud Found By Government In Medicare and Medicaid

MAY 20, 1996 VOLUME 3, NUMBER 47

Last May the big news in aging was the fourth White House Conference on Aging. While the Conference did not lead to major new initiatives or approaches in dealing with aging or the elderly, one crowd-pleasing promise came from President Bill Clinton and Health and Human Services Secretary Donna Shalala. While Congress considered massive cuts in Medicare and Medicaid, many focused on fraud alleged to be rampant in both programs, the Administration announced an initiative to crack down on such fraud.

Called “Operation Restore Trust,” the anti-fraud plan targeted the five biggest states in both population and Medicare and Medicaid expenditures. Government operatives particularly looked at the programs in New York, California, Illinois, Texas and Florida.

After one year, the program claims major success. Operation Restore Trust claims to have identified and corrected $42.3 million in overpayments in the five targeted states. Since the cost of the special program was about $4 million, the Department of Health and Human Services claims a return of $10 for every dollar expended on control of fraud and waste.

Among the examples of fraud cited by the Department was one instance in which a nursing home routinely invited new residents to a get-acquainted tea. Later, one resident’s son noticed that the nursing home had charged Medicare for a group therapy session; after investigation, it turned out that the tea was being billed as therapy for all attendees.

Most of the efforts expended by Operation Restore Trust have been in nursing home, home health agency and durable medical equipment suppliers’ bills. In appropriate cases, the task force has pursued and obtained criminal convictions, fines and civil penalties against offenders, all of which have been paid into the Medicare Trust Fund or the U.S. Treasury.

The five states targeted by Operation Restore Trust account for 38.5% of the nation’s Medicaid beneficiaries and 34% of Medicare beneficiaries, according to the Department of Health and Human Services. Although only a little more than a third of Medicare and Medicaid beneficiaries are directly affected by the initiative, Department officials point out that it has given officers practice in building cases for fraud and experience in assembling cases.

Based on the claimed savings of $10 for every $1 expended, President Clinton has indicated that he will include more funds for expansion of Operation Restore Trust in his 1997 budget proposal. According to HHS Secretary Shalala, “In its first year Operation Restore Trust has proved its value and the president wants to extend its reach to every state in the nation.”

Over the next six years, Congress has proposed cutting the growth of the Medicare and Medicaid programs by a total of approximately $240 billion (President Clinton has proposed smaller cuts, totaling “only” $170 billion). Based on the first year experience of Operation Restore Trust, this initiative might be capable of reducing the cost of Medicare and Medicaid by a total of about $600 million over that same period. In other words, and aggressive fraud and waste reduction program might account for as much as three-tenths of one percent of the President’s proposed reductions, or one-quarter of one percent of the proposed Congressional reductions. Clearly, while fraud detection and reduction should be given a high priority, it will be nothing more than the proverbial drop in the budget bucket.

White House Conference on Aging Results

JUNE 5, 1995 VOLUME 2, NUMBER 48

The Fourth White House Conference on Aging met in Washington, D.C., the first week in May. After three intense days of discussion and speeches, 2225 delegates voted on over 100 resolutions. The five top priorities of the delegates were:

1. Keeping Social Security sound for now and for the future

2. Preserving the integrity of the Older Americans Act

3. Preserving the nature of Medicaid

4. Reauthorization of the Older Americans Act

5. Increasing funding for Alzheimer research

Past White House Conferences on Aging (held in 1961, 1971 and 1981) are generally credited with providing the impetus for major new programs like Medicare, the Older Americans Act and Medicaid. This session was notable for a very different focus: how to prevent wholesale cuts in existing government programs.

Even as WHCoA delegates met and discussed the need for continued viability of Social Security, Medicare and Medicaid, Congress was beginning early discussion of major cuts in the Medicare budget. One number frequently heard as a target for Medicare cuts (actually, reductions in projected growth rates) was $250 million. The coincidence that this was almost the exact cost of a tax cut also being promoted by Congressional Republicans made for some fireworks at the Conference.

President Clinton and Vice President Gore (as well as other Administration figures and leading Democrats), told cheering delegates that Republicans sought to take money from Medicare to finance tax cuts for the wealthy. Unfortunately, no major Republic figures appeared to explain their position or respond to the Administration’s broadsides.

But What Does it Mean?

For better or worse, the Fourth WHCoA was not a bipartisan, problem-solving endeavor. A truly representative group of seniors and advocates made an impassioned pitch for retention of existing programs, but no one provided alternative approaches or thoughtful analysis of the real problems facing seniors, the government and the country. The only clear message of the Fourth WHCoA was “save our programs–look somewhere else for cuts.”

Questions and Answers

Q: “Is it necessary to have two witnesses sign health care powers of attorney and Living Wills?”

A: No. A single witness (who may, but need not, be a notary) is sufficient. If there is only one witness, it may not be an heir or devisee (someone who will receive money upon the death of the signer). No similar restriction exists if there are two witnesses.

White House Conference on Aging (Conclusion)

APRIL 17, 1995 VOLUME 2, NUMBER 41

Previous Elder Law Issues have described proposals considered by the Arizona delegation to the WHCoA. This (final) installment of the series will focus on the two remaining topic areas under discussion.

“Special” Populations

Among the concerns of Arizona delegates to the WHCoA are the specific problems of minority, rural, ethnic and disabled elderly. Some of the proposals discussed by the delegation relate to those special populations.

Adapt program eligibility standards to consider chronic illness, social and geographic isolation and lack of preventive health practices (all more frequent among minority and rural populations).

Continue the SSI program, and increase benefits and eligibility to federal poverty levels.

Exclude SSI from block grant proposals.

Target special populations in program outreach efforts.

Provide transportation for program beneficiaries, particularly in rural areas.

Encourage (or require) medical schools to focus health care delivery on special populations.

Require multilingual and multicultural staff in programs serving the elderly.

Permit program flexibility to reach and provide services to minority, rural and disabled elderly.

Involve volunteers in efforts to overcome language and ethnic barriers.

Recruit and promote minority group members to policy making levels in agencies and committees.

Increase training for service providers.

Elder Rights

Suggestions for enhancement of personal integrity and dignity:

Continue funding and enforcement under the Older Americans Act.

Focus more resources on providing affordable, secure and safe housing for the elderly.

Require minimum standards for guardianship, conservatorship and other legal proceedings.

Expand the Ombudsman program under the Older Americans Act.

Enhance programs providing for intergenerational contacts.

Establish multi-generational housing, utilizing elderly residents for teaching, child care and similar functions.

Improve access to transportation for seniors.

On to Washington

The WHCoA begins in two weeks. If you feel strongly about any of the suggestions described in the last three Elder Law Issues, or if you have suggestions of your own, feel free to contact any of the delegates to the Conference; you can reach delegate Robert Fleming at the address in our masthead or at the FAX number below.

White House Conference on Aging (Cont’d)

APRIL 10, 1995 VOLUME 2, NUMBER 40

More proposals considered by Arizona delegates to the White House Conference on Aging (by topic area):

Health Care and Mental Health

  • Permit reimbursement for direct care provided by nurse practitioners and physician’s assistants, for home care, preventive care and wellness programs.
  • Reduce duplication and coordinate services, particularly for those who access special services such as Veteran’s programs, Indian Health Services and Medicaid.
  • Control prescription medication costs.
  • Avoid rationing of health care by caps on service reimbursement and cost-benefit analysis of the true value of high-cost medical procedures.
  • Use excess hospital capacity for alternative services, such as extended care and assisted living.
  • Share medical resources, particularly high-tech equipment.
  • Consider means-testing Medicare (though a strong minority voice opposed any discussion of such a step).
  • Expand health programs to include mental health services.
  • Promote greater patient involvement in medical decisions.
  • Deal more creatively with substance abuse and suicide among the elderly.
  • Encourage medical professionals to work in rural and under served populations.
  • Institute a single-payor national health program (though this one did not make it into the final report).

Long Term Care

  • Shift emphasis from long term care in medical institutions to home care.
  • Provide tax incentives for family caretakers.
  • Encourage innovation in state and local programs by granting federal program waivers.
  • Promote prevention practices, among both elderly and young.
  • Encourage seniors to volunteer in their communities, to help them stay vital and involved.
  • Develop a wellness check program for homebound seniors.
  • Provide loans and incentives for home repair and adaptation for the homebound elderly.
  • Increase recreational programs for the elderly.
  • Expand case management programs.
  • Provide respite care for family care givers.
  • Promote congregate housing alternatives to reduce care costs.
  • Promote family and community responsibility for the elderly.

These are just a few of the myriad of suggestions considered by Arizona delegates. Next issue, we will discuss “special populations” and “elder rights.”

White House Conference on Aging


The White House Conference on Aging will convene in Washington, D.C. on May 2, 1995. For four days, delegates from around the country will discuss issues of importance to an aging American population.

Among the delegates will be four Pima County residents: Elder Law Issues Publisher Robert Fleming, PCOA Executive Director Marian Lupu, Univ. of Arizona Professor Theodore Koff, and former Social Security Commissioner Charles Schottland.

In previous Elder Law Issues, we have described some of the issues Arizona delegates wrestled with during the Arizona conference in January. Beginning with this issue, we will give you some insight into the issues that Arizona delegates thought important for the national agenda.

Issues on the Agenda

The Arizona conference dealt with five areas of concern for aging Arizonans. Those topic areas (more thoroughly described in previous Elder Law Issues) included:

  • Financial and Income Security
  • Health Care and Mental Health
  • Elder Rights
  • Long Term Care
  • Special and Minority Aged Populations

Not surprisingly, many of the ideas and concerns developed by the Arizona conference had been discussed and debated in previous forums. A sampling of the Social Security proposals and recommendations from the Arizona conference:
Isolate Social Security from other budget items, to preserve the programs viability and deal with anticipated future demands.

Reduce the federal deficit or, in other words, improve the quality of Social Security investments by avoiding use of Social Security to subsidize debt costs.

Streamline the Social Security Administration itself as a way to cut costs.

Consider means testing Social Security, but only if absolutely necessary (two of five separate discussion groups at the Arizona conference adamantly opposed any consideration of means testing).

Raise the wage cap on taxable salaries to generate more revenues.

Educate Americans to the reality that Social Security is intended to be a supplement to other retirement programs.

Encourage healthy seniors to remain employed longer by removing the cap on earnings for recipients (one discussion group adamantly opposed this solution, believing that the program would be seriously hurt financially).

Next Issue

Beginning next issue, Elder Law Issues will capsulize conference recommendations in other areas.

“Do Not Resuscitate” Tattoo


You may have read about Indianan Maria Rodriguez. She is the 40-year-old nurse who has had the words “No Code,” and the instructions “Pain and comfort only. Organ donor” tattooed on her stomach. In addition, her creative design includes a human heart with a circle and slash over it (the universal symbol for “no”).

While many patients might agree with Ms. Rodriguez’ sentiments, few are likely to go to the same trouble to make wishes known to paramedics and emergency room personnel. However, even if the question is purely academic we might consider whether Ms. Rodriguez has written a valid “living will” under Arizona law.

Like many states, Arizona has adopted laws recognizing several different types of “advance directives.” Most commonly, they include living wills and durable powers of attorney for health care. Ms. Rodriguez’ tattoo would not qualify as either, since it is not signed by her or properly witnessed.

Arizona also recognizes “pre-hospital medical care directives,” a category of directives intended to deal with exactly Ms. Rodriguez’ concern. By executing such a directive, a patient can direct that she would not want to be resuscitated by paramedics or emergency room personnel. These instruments, however, must be on orange paper and either letter-size or wallet-size. Ms. Rodriguez’ tattoo does not qualify.

So can nurse Rodriguez’ tattoo be dismissed as nothing more than a curiosity? No.

Even though it is not in the proper form to qualify as a formal advance directive under Arizona law, it is a potent and persuasive expression of her wishes. Since surrogate decision-makers (including agents under powers of attorney, guardians and family members) must take into consideration the wishes of the patient, the tattoo can and should be given considerable weight in gauging Ms. Rodriguez’ desires. Ms. Rodriguez has taken an original and effective step toward ensuring that her wishes are honored. Few providers will forget her wishes.

White House Conference on Aging

For the past five weeks, Elder Law Issues has described the topics focused on by Arizona’s Conference on Aging held in January. That conference was Arizonans’ chance to help shape the agenda for the full White House Conference on Aging.

The national Conference will be held in Washington, D.C., the first week of May, 1995. Within the next few weeks, we will tell you more about the Arizona conference’s recommendations and conclusions.

Arizona White House Conference on Aging


The Arizona White House Conference on Aging held in Phoenix last month dealt with issues facing the full White House Conference on Aging when it meets in May. Arizona’s delegation dealt with several issues expected to dominate the national aging agenda.

Long Term Care

Everyone knows that the proportion of elderly citizens is expected to grow dramatically in the next two decades. What many do not appreciate is that the greatest growth is projected for the “old old”; those over age 85. Currently one-quarter of all women (but only one-seventh of men) over age 85 live in nursing homes. Those who turn 65 in any given year have about a 40% chance of spending some portion of the rest of their lives in a nursing home. About 10% of those will spend five or more years there.

Another tremendous segment of the population requires long-term care, but receives care at home. About 70% of all long-term care of the elderly is provided solely by family and friends, without institutionalization.

For those who can be cared for at home, the cost of assistance may be prohibitive. Simply bringing an aide into the home three times a week for meal preparation and light housekeeping can easily cost in the range of about $600 per month. Since about 20% of Arizona’s elderly live at or near the federal poverty level, even such small assistance may be unaffordable.

For those placed in nursing homes in Arizona, the cost of care will typically vary from $30,000 to $40,000 per year. Many seniors expect Medicare to pay some portion of that cost; in fact, Medicare pays only about 3% of the total nursing home bill in this country. Private long-term care insurance (still a relative rarity) and Veteran’s benefits account for another percent or two each; the remaining portion of long-term care costs are paid roughly equally by Medicaid and patient’s private savings and income.

Although nursing homes care for less than one-fifth of those requiring long-term care, they are responsible for more than half of the cost of care. Seniors are reluctant to enter the nursing home, and much prefer to be cared for (and die) in their homes.

Cost effective alternatives to institutionalization exist, especially in urban areas. Adult day care, respite care, hospice and assisted housing programs can keep many nursing home candidates in less expensive settings and more comfortable. Unfortunately, such programs are too rare and are seldom funded by public dollars. Paradoxically, it becomes less expensive for most patients to move into the nursing home and qualify for Medicaid (ALTCS in Arizona) than to secure care at home or in a more home-like setting.

Arizona White House Conference on Aging


As mentioned in previous Elder Law Issues, the Arizona White House Conference on Aging held in Phoenix last month dealt with issues facing the full White House Conference on Aging when it meets in May. Arizona’s delegation dealt with several issues expected to dominate the national aging agenda.

Financial Security

A person nearing age 65 in this last decade of the twentieth century has a life expectancy of 85. The life expectancy for the average adult at the end of the nineteenth century was 47. Improvements in health, disease control and lifestyles have made it possible for today’s elderly to expect much longer and more productive lives.

In 1950, the average Social Security benefit was $43.86. By the 1993, the average monthly benefit for workers was $656. For widows and widowers, the average benefit was $624 in 1993.

Although Social Security was originally intended as a supplement to private retirement sources rather than as the principal source of retirement income, the result has been the opposite. Half of today’s retirees receive no pension benefits other than Social Security, and of those with second pensions nearly 60% get less than $100 per month from those sources.

Nationally, Social Security benefits provide about 40% of retiree income. Accumulated assets provide 25%, earnings 18%, and private pensions just 14%. Americans have never been good savers, and sixty years of Social Security seem to have discouraged our already low rates of saving.

As annual federal spending nears $1.5 trillion in 1995, concern mounts about the rising share of the national budget dedicated to Social Security and other “entitlements.” Unless changes are made in the way we fund Social Security, the entire budget will be required just to make the payments on Social Security and the national debt by 2011.

Some changes have already begun. The usual retirement age will raise from 65 to 67 in three decades. Some taxes are now collected on Social Security benefits for the wealthiest recipients, with the proceeds going into the Social Security system. But further changes will be required to prevent bankruptcy of the fund by the year 2029.

Meanwhile, the poorest recipients of federal largesse remain at levels inadequate to provide even basic needs. Over 1.5 million persons age 65 and above qualify for Supplemental Security Income because they receive total income (from all sources) of $458 or less.

In an era of budget constraints and shortages, the need to redesign Social Security benefits and taxes seems inevitable. The obvious challenge will be to do so in a fashion that preserves the value of the program.

[Next issue: Long Term Care]

More AZ White House Conference on Aging


As mentioned in previous Elder Law Issues, the Arizona White House Conference on Aging held in Phoenix two weeks ago dealt with issues facing the full White House Conference on Aging when it meets in May. Arizona’s delegation dealt with several issues expected to dominate the national aging agenda.

Problems of “Special” Populations

Of course, elderly citizens may also belong to minority or disadvantaged groups. Of particular concern to the Arizona White House Conference on Aging were the specific problems encountered by four subgroups:

  • Ethnic and racial minorities
  • Physically disabled,
  • Developmentally disabled,
  • Homeless, and
  • Veterans

Approximately one-quarter of all citizens belongs to a minority ethnic group. Elderly minority group members may suffer from double (or even triple or quadruple) jeopardy. In addition to the problems shared by all elderly citizens, the ethnic elderly are less likely to be home owners, are more likely to have transportation problems, and may find language and cultural barriers to securing services.
Our increasingly mobile society may cause special problems for the ethnic elderly. Divorce rates, changes in family structures (including increased frequency of grandparent custody and visitation disputes) and elder abuse (including financial abuse) may work special emotional and financial hardships for ethnic minorities.

In Arizona, Native Americans face special problems. State and Federal disputes over responsibility for services has left an especially needy population vulnerable.

Older citizens with developmental disabilities may face many of the same problems. Their problems are compounded by the fact that the aging services network is unfamiliar with their needs, and is strained by the additional demands imposed by this special population.

Physical disabilities are increasingly common among the elderly. Among the most elderly (those 85 and older), 62% of women and 46% of men need help at home or are living in a nursing home. Physical barriers are even more limiting to the elderly physically disabled than to their younger counterparts.

Homelessness is increasingly common among the elderly. Particularly the elderly mentally ill, who in previous decades would have been housed in institutions, may now be displaced.

Veterans as a group are getting older, and medical programs and facilities designated for their care are not geared to meet their changing needs. Only 10% of qualified veterans use VA facilities, yet overcrowding and long waiting periods are endemic.

[Next issue: Financial Security Issues]

More AZ White House Conference on Aging


As mentioned in last week’s Elder Law Issues, the Arizona White House Conference on Aging held in Phoenix a week ago dealt with the issues facing the full White House Conference on Aging when it meets in May. Arizona’s delegation dealt with several issues expected to dominate the national aging agenda.

Health Care and Mental Health

In 1993, expenditures for health care totaled about $903 billion in the United States. Estimates indicate that the total cost of health care may exceed $1.7 trillion by the year 2000. While the overall cost of living increases at less than 5% per year, health care costs increase more than 10% each year.

Elderly citizens are more closely affected by medical problems than the general population. Those over 65 have an average of eight medical visits per year, as opposed to the five visits made by the rest of the population. The elderly are hospitalized more than three times as often as younger patients, stay half again as long in the hospital, and use twice as many prescription drugs. The disparity is widening; elderly patients are expected to increase their contacts with physicians by 22% (from 259 million contacts to 296 million) by the turn of the century.

The federal Medicare program provides medical care to most Americans over age 65 (about 5% of the elderly are not covered by Medicare). In 1995, Medicare recipients pay $46.10 per month(an increase of over 10%) in insurance premiums to secure coverage for most medical care. Costs not covered by Medicare include eye and dental care, most prescription medications, most nursing home care and most mental health care.

In addition to Medicare Part B premiums, many elderly patients pay substantial deductibles and co-payments for their medical coverage. Others (in increasing numbers) rely on managed care (HMO) programs to reduce or eliminate co-payments.

Mental health services are particularly limited by Medicare. While Arizona has one of the highest suicide rates for over-65 patients in the nation, depression and alcoholism (the leading precursors to suicide and other behavioral health problems) are often undetected and untreated. Reimbursement rates and coverages are not conducive to appropriate and prompt treatment.

Elderly patients in rural areas face particular problems with health care. In addition to the other health issues, rural Arizonans have particular difficulties with transportation. In addition, physicians in rural areas are much more likely to refuse to accept Medicare assignment for their services.

[Next issue: “Special” Elderly Populations]

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