Improved Oversight Needed to Protect Nursing Home Residents from Abuse

What GAO Found

The Centers for Medicare & Medicaid Services (CMS) is responsible for ensuring nursing homes meet federal quality standards, including that residents are free from abuse. CMS enters into agreements with state survey agencies to conduct surveys of the state’s homes and to investigate complaints and incidents. GAO analysis of CMS data found that, while relatively rare, abuse deficiencies cited in nursing homes more than doubled, increasing from 430 in 2013 to 875 in 2017, with the largest increase in severe cases. GAO also reviewed a representative sample of abuse deficiency narratives from 2016 through 2017. Physical and mental/verbal abuse occurred most often in nursing homes, followed by sexual abuse, and staff were more often the perpetrators of the abuse deficiencies cited. CMS cannot readily access information on abuse or perpetrator type in its data and, therefore, lacks key information critical to taking appropriate actions.

GAO Analysis of a Representative Sample of CMS Nursing Home Abuse Deficiency Narratives, 2016-2017

Note: Percentages do not add to 100 because some narratives had multiple types of abuse, were missing or incomplete, or were not consistent with CMS’s definition of abuse.

GAO also found gaps in CMS oversight, including:

Gaps in CMS processes that can result in delayed and missed referrals. Federal law requires nursing home staff to immediately report to law enforcement and the state survey agency reasonable suspicions of a crime that results in serious bodily injury to a resident. However, there is no equivalent requirement that the state survey agency make a timely referral for complaints it receives directly or through surveys it conducts. CMS also does not conduct oversight to ensure that state survey agencies are correctly referring abuse cases to law enforcement.

Insufficient information collected on facility-reported incidents. CMS has not issued guidance on what nursing homes should include when they self-report abuse incidents to the state survey agencies. Officials from all of the state survey agencies in GAO’s review said the facility-reported incidents can lack information needed to prioritize investigations and may result in state survey agencies not responding as quickly as needed.

Why GAO Did This Study

Nursing homes provide care to about 1.4 million nursing home residents—a vulnerable population of elderly and disabled individuals. CMS, an agency within the Department of Health and Human Services (HHS), defines standards nursing homes must meet to participate in the Medicare and Medicaid programs.

GAO was asked to review abuse of residents in nursing homes. Among other objectives, this report: (1) determines the trends and types of abuse in recent years, and (2) evaluates CMS oversight intended to ensure residents are free from abuse.

GAO reviewed CMS’s policies, analyzed CMS data on abuse deficiencies from 2013 through 2017, the most recent data at the time of our review, and interviewed officials from CMS and state survey agencies in five states, as well as other key stakeholders in those states such as ombudsmen and law enforcement officials. The states were selected for variation in factors such as number of nursing homes and role of other state agencies in abuse investigations.

What GAO Recommends

GAO is making six recommendations, including that CMS: require state survey agencies to submit data on abuse and perpetrator type; require state survey agencies to immediately refer to law enforcement any suspicion of a crime; and develop guidance on what abuse information nursing homes should self-report. HHS concurred with all of GAO’s recommendations and identified actions it will take to implement them.

For more information, contact John Dicken at (202) 512-7114 or dickenj@gao.gov.

https://www.gao.gov/products/GAO-19-433

Bright Health To Expand Medicare Advantage To 6 More States in ’20

Bright Health is the latest health insurer to announce plans to sell private Medicare Advantage plans in several new markets, hoping seniors flock to such coverage following federal rule changes that allow plans to offer more benefits.

The startup insurer said it will add seven new markets in six states for 2020. They are: the Orlando and Daytona areas of Florida; Palm Beach, Fla.; Chicago, Illinois; Omaha, Neb.; the Cleveland and Akron area of Ohio; Greenville, South Carolina and Memphis Tennessee. Bright Health currently sells Medicare Advantage plans in six metropolitan markets: Birmingham, Ala; Phoenix, Arizona; Denver, Colo.; New York City: several Ohio cities including Cincinnati and Nashville, Tenn.

Bright Health’s expansion into new regions is the latest expansion for such plans, which contract with the federal government to provide extra benefits and services to seniors, such as disease management and nurse help hotlines with some also offering vision, dental care and wellness programs. And now insurers are rolling out more supplemental benefits in their Medicare Advantage plans following rule changes implemented.

In Bright Health’s case, the new Medicare offerings are part of a major expansion of all of its business lines that include individual coverage, “family plans,” Medicare Advantage and supplemental Medicare plans.

In all, Bright Health said it will begin selling its array of plans in 13 new markets across seven states beginning next year. “This market expansion brings Bright Health Plan’s footprint to a total of 22 markets in 12 states, building on its sizable growth last year when it added products in Arizona, New York, Ohio and Tennessee,” the company said in its announcement Wednesday.

The expansions are still subject to final regulatory approvals by state insurance departments, but executives say the expansion shows financial strength and confidence consumers and investors have in the company.

“In just four years, we’ve grown from serving consumers in our pilot market of Colorado to serving tens of thousands of members across six states,” Bright Health CEO Bob Sheehy said. “This substantial growth shows that consumers are hungry for a new healthcare model that is simple, personal and more affordable. We’ve been able to meet this demand because our Health Plan Care Partner Model allows us to scale quickly and effectively, and our significant expansion in 2020 is further validation of that.”

https://www.forbes.com/sites/brucejapsen/2019/07/24/bright-health-to-expand-medicare-advantage-to-six-more-states-in-2020/#58f7e8b12a82

Centene Latest Insurer to Plan Big Medicare Advantage Expansion

The health insurer Centene plans to expand into 100 new counties and enter a new state – Nevada – to expand privatized Medicare coverage to seniors in 2020.

Centene is joining the parade of established health plans and startups looking to take advantage of new rules that allow Medicare Advantage plans to offer more benefits to seniors.

“We are no longer simply a Medicaid healthcare company,” Centene CEO Michael Neidorff told analysts Tuesday morning on the company’s second-quarter earnings call.

To be sure, Centene is perhaps best known for administering Medicaid coverage for the poor via contracts with states across the country. Medicaid membership was up 18% in the second quarter to nearly 8.5 million compared to the year-ago period, Centene reported Tuesday.

Centene is also the nation’s biggest player in Obamacare, the subsidized individual coverage under the Affordable Care Act with more than 1.9 million members. That business grew from 1.5 million at the end of the second quarter last year.

Driven by strong performance in the ACA’s individual coverage and Medicaid, Centene said profits rose to $561 million, or $1.36 per share, compared to $360 million, or 90 cents in the year ago quarter. Revenue jumped 29% to $18.4 billion.

Centene expects medical costs of its members to be stable and announced plans to raise earnings guidance for the rest of the year based on improving margins from its Obamacare business.

Looking ahead, Centene sees promising growth in Medicare Advantage. Its Medicare business now, which includes Medicare Advantage and related coverage for seniors rose by more than 50,000 in the quarter to nearly 400,000.

Centene will also greatly expand its Medicare Advantage business following the close of its acquisition of WellCare Health Plans. Centene executives say they expect to have to divest some operations of the combined company to win regulatory approval but executives didn’t disclose Tuesday what those divestitures will be.

Centene’s expansion into new regions to offer Medicare Advantage is the latest expansion for such plans, which contract with the federal government to provide extra benefits and services to seniors, such as disease management and nurse help hotlines with some also offering vision, dental care and wellness programs. And now insurers are rolling out more supplemental benefits in their Medicare Advantage plans following rule changes implemented.

“Next year, we plan on expanding into 100 counties in existing states—and adding one new state—Nevada,” Neidorff told analysts Tuesday morning. “We will begin our joint venture with Ascension in 4 geographies in 2020. Further, Centene will return to a four star MA parent rating—and the addition of WellCare’s top performing MA portfolio will bolster our MA platform.”

https://www.forbes.com/sites/brucejapsen/2019/07/23/centene-plans-big-medicare-advantage-expansion/#1cd1550815f5

Clue to ‘maternal instinct’

Oxytocin is widely referred to as the love hormone and plays an important role in the regulation of social and maternal behavior. In recent years, the oxytocin system in the brain has received tremendous attention as key to new treatments for many mental health disorders, such as anxiety, autism spectrum disorders and postpartum depression. New research led by a biologist and his students at LSU have discovered a group of cells that are activated by oxytocin in one area of female mouse brains that are not present in the same area in male mouse brains.

“Many researchers have attempted to investigate the difference between the oxytocin system in females versus males, but no one has successfully found conclusive evidence until now. Our discovery was a big surprise,” said Ryoichi Teruyama, LSU Department of Biological Sciences associate professor, who led this study published in PLOS ONE.

The oxytocin receptor cells are present in the brain area thought to be involved in the regulation of maternal behavior. Moreover, the expression of oxytocin receptors in these cells are only present when estrogen is also present. These imply that these cells are involved in inducing maternal behavior. In addition, it confirms what many recent human studies have shown: there is a connection between an altered expression of oxytocin receptors and postpartum depression.

Postpartum depression contributes to poor maternal health and has negative effects on a child’s development. A number of studies have found that children of depressed mothers are at risk for a wide range of cognitive, emotional, behavioral and medical problems. Therefore, postpartum depression is a major public health concern that has significant adverse effects on both mother and child. About 10 to 20 percent of women experience postpartum depression after childbirth.

This new discovery that occurred at LSU opens doors to potential new treatments and drugs for postpartum depression targeting oxytocin receptor cells.

“I think our discovery could be universal to all mammals that exhibit maternal behavior, including humans,” Teruyama said.

Student researchers

Study co-author Ryan LeBlanc from Denham Springs was an undergraduate student researcher at LSU whose work was instrumental to this discovery. However, he had little previous research experience before joining Teruyama’s lab.

Teruyama recalled that when LeBlanc first approached him to be his mentor, he asked him about his hobbies. LeBlanc said he liked to build plastic models of battleships.

“I certainly don’t know much about battleship plastic models, but anyone who can assemble 500 to 2,000 plastic parts into models must be persistent, focused and exceedingly careful. I accepted him gladly thinking he is going to find something extraordinary, and I was right,” Teruyama said.

LeBlanc took on the tedious task of finding and marking the exact location of thousands of oxytocin receptor cells with a red pen. He spent more than a month identifying the cells, which was instrumental to this discovery.

Current LSU doctoral candidate Kaustubh Sharma from Nepal is the first author who validated LeBlanc’s finding. Sharma is currently investigating if the oxytocin receptor cells regulate maternal behavior in female mice.

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Story Source:

Materials provided by Louisiana State University. Note: Content may be edited for style and length.

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Journal Reference:

1. Kaustubh Sharma, Ryan LeBlanc, Masudul Haque, Katsuhiko Nishimori, Madigan M. Reid, Ryoichi Teruyama. Sexually dimorphic oxytocin receptor-expressing neurons in the preoptic area of the mouse brain. PLOS ONE, 2019; 14 (7): e0219784 DOI: 10.1371/journal.pone.0219784

https://www.sciencedaily.com/releases/2019/07/190725151017.htm

Medications used to treat atrial fibrillation may raise risk of falls

For older adults, fainting and falls are serious health concerns. They can lead to injury, hospitalization, and other severe consequences. Having certain chronic conditions, as well as taking certain medications, can raise your risk of experiencing falls and fall-related injuries.

One condition that contributes to fainting and falls is atrial fibrillation. Atrial fibrillation occurs when the upper (atrial) part of your heart contracts rapidly and irregularly (fibrillates). Atrial fibrillation may be continuous or occasional and is the most common irregular heart rhythm in older adults. It occurs in three to five percent of people over age 65.

To prevent atrial fibrillation symptoms, health professionals may treat patients with medications to control their heart rate or rhythm. However, these medications can potentially raise the risk for falls and fainting, though the connection hasn’t studied significantly in the past.

To learn more, researchers in Denmark designed a study to learn more about the potential risk for falls and fainting among older adults taking medication for atrial fibrillation. Their study was published in the Journal of the American Geriatrics Society.

Using Danish health data, the researchers identified patients who were between the ages of 65 and 100 when they were first diagnosed with atrial fibrillation. The researchers examined the records of 100,935 atrial fibrillation patients 65 years or older who filled prescriptions for heart rhythm medications.

The researchers examined the medication the patients took to control their heart rhythms. Prescriptions were for beta-blockers, certain calcium channel blockers (diltiazem, verapamil), and digoxin. Other medications included amiodarone, flecainide, and propafenone.

Then the researchers looked for those patients who had emergency department visits or hospital admissions for fainting, fall-related injuries, or both. Fall-related injuries were defined as fractures of the thigh, elbow, forearm, wrist, shoulder or upper arm, pelvis, and skull, as well as major and minor head injuries.

The researchers followed the patients for about two and a half years. During the follow-up period:

• 17,132 (17 percent) had a fall-related injury
• 5,745 (5.7 percent) had a fainting episode
• 21,093 (20.9 percent) had either a fall-related or fainting-related injury

There were 40,447 deaths without a fall-related injury or fainting episode, which accounted for 40.1 percent of study participants.

The researchers reported that the medication amiodarone was significantly associated with increased risk, whether it was prescribed alone or with other heart rhythm drugs. The medication digoxin was slightly associated with fall-related injuries.

The researchers also learned that people were at higher risk for an injury within the first 90 days of treatment, and especially within the first 14 days of treatment.

“Our findings add evidence that, for older patients with atrial fibrillation, treatment with amiodarone is associated with a higher risk of fall-related injuries and fainting,” said the researchers. Additionally, the amiodarone connection was strongest within the first two weeks of the treatment but still present after long-term treatment.

The researchers concluded that being informed on the adverse risks of a given treatment is crucial to make shared decisions and provide quality patient care.

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This summary is from “Rate- or Rhythm in Older Atrial Fibrillation Patients: Risk of Fall-related Injuries and Syncope.” It appears online ahead of print in the June 2019 issue of the Journal of the American Geriatrics Society. The study authors are Frederik Dalgaard, MD; Jannik Langtved Pallisgaard, MD, PhD; Anna-Karin Numé, MD; Tommi Bo Lindhardt, MD, PhD; Gunnar Hilmar Gislason, MD, PhD; Christian Torp-Pedersen, MD, DMSc; and Martin H. Ruwald, MD, PhD.

https://www.eurekalert.org/pub_releases/2019-07/ags-mut072619.php

Liver transplants could be redundant with discovery of new liver cell

Researchers at King’s College London have used single cell RNA sequencing to identify a type of cell that may be able to regenerate liver tissue, treating liver failure without the need for transplants.

In a paper published today in Nature Communications, the scientists have identified a new type of cell called a hepatobiliary hybrid progenitor (HHyP), that forms during our early development in the womb. Surprisingly, HHyP also persist in small quantities in adults and these cells can grow into the two main cell types of the adult liver (Hepatocytes and Cholangiocytes) giving HHyPs stem cell like properties.

The team examined HHyPs and found that they resemble mouse stem cells which have been found to rapidly repair mice liver following major injury, such as occurs in cirrhosis.

Lead author Dr Tamir Rashid from the Centre for Stem Cells & Regenerative Medicine at King’s College London said: “For the first time, we have found that cells with true stem cell like properties may well exist in the human liver. This in turn could provide a wide range of regenerative medicine applications for treating liver disease, including the possibility of bypassing the need for liver transplants.”

Liver disease is the fifth biggest killer in the UK* and the third most common cause of premature death, and the number of cases is continuing to rise. It can be caused by lifestyle issues such as obesity, viruses, alcohol misuse or by non-lifestyle issues such as autoimmune and genetic mediated disease.

Symptoms of liver disease include jaundice, itching and feelings of weakness and tiredness and in more severe cases, cirrhosis. The only treatment for severe liver diseases at present is a liver transplant which can lead to a lifetime of complications and for which the need for donor organs greatly outweighs the increasing demands.

“We now need to work quickly to unlock the recipe for converting pluripotent stem cells into HHyPs so that we could transplant those cells into patients at will. In the longer term, we will also be working to see if we can reprogramme HHyPs within the body using traditional pharmacological drugs to repair diseased livers without either cell or organ transplantation,” said Dr Rashid.

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*Figures from Public Health England

https://www.eurekalert.org/pub_releases/2019-07/kcl-ltc072619.php

Concern on accuracy of widely used dementia test spurs training requirement

Last year, Dr. Ronny Jackson, then the White House physician, gave Donald Trump a standard test to detect early signs of dementia — and said the president had scored a perfect 30. “There is no indication whatsoever that he has any cognitive issues,” Jackson said at the time in front of TV cameras.

Trump’s team embraced the result, with Donald Jr. boasting on Twitter: “More #winning.” The publicity sparked a wave of interest in the screening tool. Much was written about what the test showed – or didn’t – about the president’s mental acuity. A media outlet even posted its questions online, suggesting readers could measure whether they were “fit to be U.S. president.”

Dr. Ziad Nasreddine, the creator of that test, the Montreal Cognitive Assessment, went with it. Within weeks, the Lebanese-Canadian neurologist and his colleagues were working on “mini-MoCA,” an online exam for anyone to take who was worried about his own cognitive decline. Nasreddine said at the time that he might charge the masses $1 or $2 per test.

Now Nasreddine has changed course. He says growing worries about the validity of test results — and possible liability for errors — have pressed him to require those who administer the test to pay for mandatory certification to make sure the results are accurate.

Further examination of the results called into question even perfect scores.

“I’ve seen so much variability, which might make us reconsider some of the decisions made based on the MoCA score,” said Nasreddine, who has reviewed hundreds of exams administered to patients in recent years.

Training and certification have been voluntary for years. But starting Sept. 1, most clinicians who administer the MoCA will be required to complete a one-hour, $125 online course, said Nasreddine, who holds the copyright to the test.

Nasreddine, director of the MoCA Clinic and Institute in Quebec, Canada, wouldn’t speculate about whether Trump’s test was accurate. Officials with the White House and the Navy, where Jackson is a rear admiral, did not respond to questions about the issue. Jackson did not reply to an email seeking comment.

The move to require certification — and particularly to charge for it — sparked outrage among geriatricians like Dr. Eric Widera of the University of California, San Francisco. He accused Nasreddine of creating a “pay to play” scenario that profits from a growing need and the test’s ubiquitous use.

“It raises huge red flags,” Widera said. “This is a growing issue, the monetization of tools that we promoted as the standard.”

It’s a controversial change for an exam that is used by doctors and other health professionals in nearly 200 countries to screen people for potential problems with memory and thinking.

In the U.S., the MoCA is a go-to tool used in about 8,000 visits each year to the 31 Alzheimer’s Disease Research Centers funded by the National Institute on Aging. The 30-question test assesses different cognitive domains through exercises that include drawing a cube, drawing a clock with hands set at a specific time, naming certain animals, memorizing a series of words and calculating numbers in a certain way.

Until now, the MoCA screen has been free for clinicians, making it a cheap, easy way to tell if someone should proceed to the more detailed evaluations used to make an actual diagnosis of dementia.

After Sept. 1, 2020 — a year after the training requirement begins — access to the test will be restricted to certified users, Nasreddine said. Only medical students, residents and fellows, and neuropsychologists will be exempt. Two-year recertification is optional and will be offered at half the original cost. Group rates will be available for institutions and government bodies to make the training affordable.

Still, Widera said he worries that requiring MoCA certification will deter nonspecialists from testing for early signs of dementia.

Studies estimate that somewhere between about 500,000 and 1 million Americans age 65 or older will develop Alzheimer’s disease this year.

Nasreddine said he has seen testing errors after reviewing hundreds of MoCA exams given by doctors and others who didn’t properly follow a four-page list of directions.

A MoCA score of 26 or higher is generally considered normal, while a score of 18 to 25 can indicate mild cognitive impairment, and 10 to 17 can indicate moderate impairment. A score of less than 10 indicates severe impairment.

On some tests, scores varied by as much as five points in the same patient over a few weeks, Nasreddine said.

“That is a lot of points out of 30,” he said. “If it’s within the same month, it’s not because the disease changed that quickly.”

Widera and others acknowledged that errors can occur in administering and interpreting the MoCA or any tool.

“There may be operator error,” he said. “That’s true for everything we do in medicine. Nobody licenses us every two years to use a stethoscope.”

Nasreddine said he and his team have been threatened with lawsuits — though it appears no cases have been filed — by people who said they were harmed by the results of tests given by health professionals who lack specialized dementia training.

“One man, they stripped him of his legal rights, put him in the nursing home, all because he scored 15 or 20 on the MoCA test,” said Nasreddine, who in addition to running a memory clinic is an assistant clinical professor at McGill University and University of Sherbrooke in Canada.

A nurse who had been having mild attention problems lost her job “because the psychiatrist who ran the test on her was not trained and didn’t do it well,” Nasreddine said, adding, “They’re blaming us.”

Regular users of the MoCA likened the controversy over the exam to the recent fate of another cognitive screening tool, the Mini-Mental State Examination.

That test, known as the MMSE, was used widely for 30 years before its authors began enforcing copyright protection and then granted an exclusive license to a third-party firm. A licensed version of the MMSE is now sold for $89 for a package of 50 tests.

The parallel upset experts like Dr. Louise Aronson, a UCSF professor of geriatrics and author of the best-selling book “Elderhood: Redefining Aging, Transforming Medicine, Reimagining Life.”

“First we gave up the #MMSE and now we will renounce the #MOCA,” Aronson tweeted on June 28. “Lessons in putting profit ahead of patients and #healthcare. Disappointing is the most polite word I can think of.”

Nasreddine said he has received many emails from MoCA users happy with the mandatory certification, adding that “the purpose of the training is to make the test more reliable and valid.”

Worries about accuracy of widely used dementia test prompt training requirement