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Carter budget cuts programs for the elderly aid for financially troubled nursing homes
NEWS WATCH Carter Budget to Cut Programs for the Elderly
credited skilled nursing facility. • Elimination of all proposed federally funded home health care demWHERE THE AXE WILL FALL onstration projects that were to have WASHINGTON, D.C.-President program for the aged and the elderly been sponsored by the Health SerCarter has proposed substantial cut- handicapped. vices Administration. backs in federally assisted programs • $70 million from rehabilitation Since the announcement of the for the aged in his fiscal 1981 loans to assist communities in subsi- Carter budget, key members of Conbudget. dizing physical rehabilitation pro- gress have called for additional cut"Restrictive" was the word James grams for the aged. backs in social services, to curb inflaT. McIntyre, director of the Presi• $20 million from Medicare for tion. Chairperson of the Senate Agdent's Office of Management and ing Committee, Lawton Chiles (D.Budget, used to describe the Fla.), supported further reducCarter proposals. tions. in human services as "a In an interview with GN, necessary means of stemming McIntyre said that "although inflation." the budget plans an overall inThe House Budget Commitcrease of approximately 4 pertee has already taken the first cent for programs for the elderstep toward trimming federal ly, the inflationary rate makes expenditures by endorsing cuts the 1981 outlays considerably of $ 15.9 billion in. the budget. lower than federal spending for that Mr. Carter submitted. the aged in 1980." Most of those reductions will The administration projects come from substantial reducmajor increases in federal revetions in social programs. nues that will reach over $600 Rural housing programs for billion in 1981.Military spendthe elderly poor were particuing is scheduled to increase larly hard hit by Housing and over 7 percent this year. In Urban Development's request . comparison to these increases, for the construction of only current programs to assist the 10,000 new housing units for Pnsidmt Carter: Cutbacks in services for the elderly will be cut and virtually the aged poor during 1981. no new programs are slated to be aged are "unfOl1Unste." White House officials confirm launched. that the President is considering reMedicare and Medicaid will re- the reimbursement of nursing costs moving the housing factor from the ceive overall increases of 4 percent of elderly patients awaiting transfer consumer price index. The housing and 3713 percent, respectively, during from an acute care hospital to an accost factor is a key figure that deter1981. However, the inflationary rate mines the annual cost of living adis projected by government econo- As GN went to press justments for S.S.I. recipients. mists to reach·if not exceed 20 perThe federal food stamp program A YOW to fight cutbacks in services will be discontinued for. June and. . for· the aged has been made by or. cent in the coming year. Among. specific budget cuts are: July due to lack of funds, the I;>ept. ganizations that advocate rights for • New limits. on reimbursement of agriculture announced on April the elderly. Leslie Kwass, chairperfor hospital costs that will cut $125 17. Three bills to provide an addi- son of the Gray Panther National million from Medicare.' tional $2.65 billion for the program Steering Committee, told GN, • An end to payment of the nurs- are before Congress. The federal "Those hurt most by cutbacks are ing cost differential for care of Med- government must notify each state of the elderly poor who, unlike the aged icare patients. Proposed cut-$191 its authority to distribute stamps for as a group, do not Yote and suffer million. the month of June by May 15. House from this lack of representation." • '$1.5 million slashed from funds Agriculture Committee members do A White House press officer acslated by the Office of Human De- not believe passage of the necessary knowledged in an interview with GN velopment Services for research appropriation bills is possible before that Mr. Carter's budget cuts would the end of July. Approximately 20 inevitably adversely affect the elderprojects on the needs of the elderly. • $9 million from Housing and million persons in the U.S. presently ly, but added that the President reUrban Development's assistance ,--r_e_ce_i_v_e_~_Ood __s_ta_m......:..p_s._· ---J gretted this as "unfortunate."
6 Geriatric Nursing May/June 1980
The 'Medigap' Scandal Abuses in the Sale of Supplementary Health Insurance to the Aged Two-thirds of all Americans over age 65, approximately 15 million people, own at least one "medigap" supplementary health insurance policy. The overwhelming majority of them have been sold inadequate coverage, and many are being defrauded. A two-year study by the House Select Committee on Aging has found widespread abuses in the sale of health insurance that supplements Medicare. Committee News chairperson Claude Pepper Close-up (D.-Fla.) estimates that . the elderly may be spending as much as $1 billion a year for worthless insurance policies purchased to pay the medical bills that Medicare does not reimburse them for. Medicare now pays less than 38 percent of health care costs, according to U.S. Dept. of Health and Hu-
man Services statistics. In order to protect themselves against financial ruin in the event of major illness, the elderly purchase medicare supplement or "medigap" policies. The enormous variety of policies and lack of consumer information make it extremely difficult to choose coverage that is adequate and economical, a 1978 Federal Trade Commission staff report concluded. Investigators for the Pepper committee discovered how vulnerable the elderly are to friendly young insurance agents who use high pressure sales techniques. Many aged persons are lonely, weak, and frightened. The salesman may be one of their few visitors, or their only visitor. The results are horrendous. For example: • An 80-year-old Pennsylvania woman spent over $50,000 on 31 policies over a three-year period. She took out a $3,000 bank loan to help make payments. • An 87-year-old Wisconsin woman purchased 19 different policies, which cost $4,000, from six agents representing nine companies. Most of her policies, like the others listed
here, were worthless because of duplication. • An Illinois woman was induced to mortgage her farm to buy 71 policies, most of them since 1976. • An 84-year-old Texas woman paid over S15,303 for 23 policies. Investigation revealed that among the items she was led into believing were insurance policies were several worthless vehicle warranty contracts and a deed to valueless Texas land. Just what techniques do salesmen use to deceive their clients? Former medigap agents have told GN about a number of practices they say are common: • Using brochures that describe fictitious coverage. • Advising elderly clients who already have insurance to let their present policies lapse and buy new, more expensive, and supposedly better policies. The agent receives a commission on the new policy. • Passing the names of particularly vulnerable and often seriously ill persons from agent to agent. In the industry slang these persons are called "crippies." Sometimes a group of salesmen
This U.S. Government hidden·camera photograph shows two senior citizen volunteers being persuaded to drop their existing coverage and buy more expensive policies, which are inadequate. (L to R) Volunteera Elizabeth Deitelhoff and Margaret Dickson, Pioneer Insurance agent William Gibson, and committee investigator David Holton (who posed aa a Pioneer trainee).
Geriatric Nursing May/June 19807
ELASf!> OINTMENT (fibrinolysin and desoxyribonuclease. combined [bovine!. ointment) DESCRIPTION. Elase Ointment is a combination 01 two lytic enzymes. fibrinolysin and desoxyribonuclease. supplied in an ointment base of liquid petrolatum and polyethylene. The fibrinolysin component is derived from bovine plasma and the desoxynbonuclease is isolated in a punfled form from bovine pancreas. The fibrinolysin used in the combination is activated by chloroform. ACTION. Combination of these two enzymes is based on the observation that purutent exudates consist largely of fibrinous material and nucleoprotein. Oesoxyribonu- . clease allacks the desoxynbonucleic acid (DNA) and fi· brinolysin attacks pnncipally "brin of blood clots and fibrinous exudates. The activity of desoxyribonuclease is limited principally to the produchon of large polynucleolides. which are less likely to be absorbed lhan the more dIffusible protein fractions tiberated by certain enzyme prepara· lions Obtained from bacleria. The fibrinolytic action 01 the enzymes in Elase Ointment is directed mainly against denatured proteins. such as those found in deVitalized tissue. while protein elements of living cells remain relatively unaffected. Elase Ointment is a combination of activ~ enzymes. This is an important consideration in treating patients suffenng from lesions resulling from impaired circulation The enzymatic action of Elase helps 10 produce clean surfaces and thuS supports healing in a variety ot exudative lesions. INDICATIONS. Etase Ointment is indIcaled for topical use as a debriding agent In a variety of inflammatory and infected lesions. These include: (1) generat surgical wounds; (2) ulcerative lesions-trophic. decubitus. stasis. arteriosclerotic; (3) second- and third-degree burns: (4) circumcision and episiotomy. Elase is used in· travaginally in: (1) cervicItis-benign. postpartum. and postconizatlon. and (2) vaginitis. PRECAUTIONS. The usual precautions against allergic reactions should be observed. particularly in persons with a history of sensitivity to materials of bovine origin or to mercury compounds. . ADVERSE REACTIONS. Side effects auributable to the enzymes have nOI been a problem at the dose and for the indications recommended herein. With higher con· cenuations. side effects have been minimal. consisting 01 local hyperemia. Chills and fever allributable to antigenic action of profibnnolysin activators of bacterial origin are not a problem with Elase. DOSAGE AND ADIIIINISTRATION. Since the condItions for which Elase Ointment is helpful vary considerably in seventy. dosage must be adjusted to the individual case; however. (he tollowing general recommendations can be made: Successlul use of enzymatic debridement depends on several factors: (I) dense. dry eschar. if present. should be removed surgically before enzymatic debridement is attempted: (2) the enzyme must be in constant contact with the substrate; (3) accumulated necrotic debris must be periodically removed; (4) the enzyme must be replenished at least once daily; and (5) secondary closure or skin grafting must be emplOyed as soon as possibte after optimal debridement has been attained It is further essentiat that ,",-ound-dressing techniques be performed carefUlly under aseptic conditions and thaI appropnate systemically acting antibiotics be administered concomitantly if. in the opinion Of the physician. they are indicated. General Topic:al Uses: Local application should be repeated at intervals for as long as enzyme action is de· sired. Alter application. Elase Ointment becomes rapidly and progressively less active and is probably exhausted for pracllcal purposes at the end of 24 hours. Infray_ginal Use: In milclto moderate vaginitiS and cerviCItis. 5 mt of Elase Ointment should be deposited deep in the vagina once nightly at bedtime for approximately five applications, or until the entire contents of one 30 g tube has been used. The patient should be checked by her physician to determIne possible need for further therapy. In mOte severe cervicitis and vaginitis. Some physiCIans prefer to initiate therapy With an application of Elase ('Ibrinolysin and desoxynoonuclease. combined [bovine]) in sOlut,on. See Elase package insert. HOW SUPPLIED. N 0071-4279-13 Elase Ointment. 30 g. The 30 g tube contains 30 units of fibrinolySin and 20.000 units of desoxyribonuclease With 0.12 mg thimerosal (mercury derivative) in a special ointment base of hQuid petrolatum and polyelhylene. NOQ71·4279·10ElaseOlnlmenl. 109 The 109 tube contains 10 units Of "brinolYSln and 6_666 units of desoxynbonuclease with 0 04 109 thimerosal (mercury derivative) In a special ointment base of liquid petrolatum and polyelhylene ThIS product also conla:ns sod!um Chloride and sucrose as Jncld~ntallngredlents YO
PARKE-DAVIS
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10 Gerialric
Nursing
May/June
1980
NEWS WATCH visit an old person and psychologically intimidate him. Other agents simply forge client signatures. Roger Deneberg, former head of the Federal Trade Commission,. told GN that "mil1ion dollar advertising campaigns are used by companies , that specialize in mail order medigap insurance.
"Popular personalities seen on TV sel1ing medigap insurance are generally selling inadequate insurance. "Most of these policies offer indemnity benefits that pay cash directly to the insured person. The payments are usually based on the number of days spent in a hospital, with maximum payments of $400 to
Percentage of Medigap Insurance Premiums Returned to The Insured in the ronn of Oaims *(Selected Companies) The "loss ratio" 01 an insurance policy is the percentage 01 premium payment returned to the insured. A medigap policy that pays you 50¢ for each dollar you spend in premiums has a loss ratio of 50%.
--=-10OJo 20% 30% 40% 50% 60010 70% 80% 90% 100%
.;:Co=m:!:p=an:.::y~
Mutual Protective Ins. Medico Life MONY New York Life American United Life National Casualty Co. American Progressive National Security InS. Reliable Constitution Life Old American Pioneer Life of Illinois Liberty National Life Pacific Mutual Businessmen's
~urance
American Exchange Life Commercial State Life Union Bankers Country Life Aid to Lutherans All American Casualty CONA Bankers Life and Casualty Guarantee Reserve Life American National American Variable Annuity Chesapeake Life Guardian Rural Mutual Mutual Benefit Life Banker's (Iowa) Home Life ·Source: House Select Commiltcc on Aging, 1979.
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$800 or possibly $1,000 a month. That may sound like a lot," Deneberg said, "but even $1,000 a month provides only $33.33 a day-far be. low current daily hospital costs and far less coverage than aged individuals should have." The Senate Committee on Aging estimates that the average senior citizen spends more than $200 a year on medigap coverage but receives an average of less than $85 a year in claims. Medigap policies pay approximately 5 percent of the health bill of the aged. Elderly Americans now pay more of their money for physician services, hospital care, and drugs than they paid before Medicare was enacted in 1966, reports the General Accounting Office. . Of more than 60 medigap policies scrutinized by the House Select Committee on Aging, fewer than 15 provided adequate coverage. But even with Medicare and the best private insurance, individuals over 65 spent an average of more than $500 for health care in 1979. Many gaps left by Medicare are not covered by any private policy. Charges for routine physical exams, medical appliances, out-of-hospital prescription drugs, dental care, and eyeglasses, for example, are billable only to the patient. Perhaps the most critical category of coverage for many of the aged is nursing home care. Medicare pays nursing home bills only when a long list of conditions are met; among them: the nursing home must be certified by Medicare; the patient's nursing home stay must follow a hospital stay of at least three days; and the patient must receive skilled nursing, not custodial care. If these and other preconditions are met, Medicare pays for the first 20 days of the nursing home stay. It also pays for days 21 to 100, except for a copayment by the patient of $20 a day. After 100 days the patient gets nothing. Private medigap insurers offer little to compensate for these serious inadequacies. Medicaid is available, but as most of the elderly know, it is a welfare. program and is available only to those living below the poverty level. In the U.S., one out of four people
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14 Geriatric Nursing May/June 1980
over 65 technically qualify for Medicaid. Are all medigap policies fraudulent? Experts say no. Numerous studies, including the House Aging Committee report, indicate that a person is best off if he or she maintains his group policy after retirement or joins a Health Maintenance Organization. If one must purchase a private policy, it is well to remember that Blue Cross/Blue Shield has been consistently awarded top marks by state and federal commissions for its medigap insurance. Several commercial insurance policies sold to individuals offer satisfactory coverage, but most do not. The elderly should be particularly careful to examine policies sold through private organizations and clubs. The outlook for legislative reform to correct the abuses in the sale of health insurance to supplement Medicare is not promising. At present, private insurance companies are not obligated to register or be certified by state or federal government. Section 508 (a) of the Social Security Act of 1979 provides that a procedure for voluntary certification be set by July 1, 1981. Even at that time, however, private companies will not be required by law to meet minimum standards with respect to adequacy of coverage, oversight of premium charge, and disclosure of information to the insured. The Senate has recently passed an amendment to H.R. 3236, The Social Security Disability Amendment of 1979, that encourages but does not force states to implement regulatory policies on the sale of medigap insurance. If individual states do not act by Jan. 1, 1982, the federal government is given authority to certify medigap insurance companies if the companies take the iniative and voluntarily request to be certified. Claude Pepper, who terms medigap insurance "a tragic national scandal," had proposed similar legislation in the form of H.R. 2602, a bill devoted to regulating medigap insurance companies. This legislation has also recently been passed by the Senate, but like the Chiles amendment, the bill calls for only voluntary certification.
Financially Troubled Nursing Homes Aided by Suspension of State Reimbursement Limit WASHINGTON, D.C.-Financially troubled nursing homes nationwide will be aided by a new federal ruling that will raise the limits placed on reimbursements paid to long-term care facilities. The Department of Health and Human Services (formerly HEW) announced in the Federal Register the suspension of a ruling that limits state reimbursement rates for all long-term care facilities to the same amount paid by Medicare. The suspension will indirectly increase federal and state payments to homes and will cost both the federal and state governments an additional $17 million each in 1981. The ruling, however, will allow many bankrupt homes to remain in operation. Ninety of the 790 nursing homes in New York State alone would have had to close their doors without the additional revenue. The action follows a temporary restraining order obtained by the New York Association' of Homes for the .Aged against a Health Care Financing Administration (HCFA) regulation that instituted reimbursement ceilings. In a related move, HHS has asked for public comment on its proposal to place Medicare cost ceilings on state' programs. The states of New York, Connecticut, Michigan, and Wisconsin have nursing home rates approved by Health and Human Services that are set higher than the limits on Medicare Reimbursement. If the proposal becomes law, industry analysts anticipate further problems for large, for-profit nursing homes. Commercial nursing homes nationwide have faced serious cash flow problems in the last decade. "Although we remain committed to keeping nursing home costs within reasonable limits," HHS Secretary Patricia Harris explained in an interview, "we do not want to penalize facilities or individual states if there is real justification for higher reimbursement rates.' "
GAO Computer Method Locates Unlicensed Boarding Homes Health Professionals Urged To Seek Implementation WASHINGTON,O.C.-Newhopes of locating the abused elderly in unlicensed boarding homes have been raised by a computer method recently devised by the General Accounting Office. The development of the computerized data retrieval process was announced by GAO in a special report to Congress: When applied to Social Security Administration records, the new system can' identify addresses to which more than three Social Security checks are sent each month. The nationwide problem of exploitative boarding homes for the elderly arose, according to the report, as a result of the government policy to deinstitutionalize the elderly and the start-up in 1974 of Supplementary Social Security Income for the aged. This added income has enabled many aged persons to leave institutions but forced them to seek out low-cost group living arrangements. Hearings in 1977 before the House Select Committee on Aging, chaired by Rep. Claude Pepper (0.Fla.), revealed that many SSI recipients were endorsing their entire checks over to boarding home operators. The hearings also publicized widespread abuses in the homes. Individual states, which are responsible for enforcing standards in boarding homes, were often not able to locate them. Rep. Pepper says that more than 75 lives were lost in these unlicensed homes in 1979 alone in fires. In im initial test, the GAO used Social Security records to locate addresses in Baltimore, Md., and Camden, N.J., where three or more checks were sent each month. After eliminating family groups and institutions, the GAO sent investigators to 38 of the addresses. Ten of the boarding homes were unknown to state officials.Among the conditions that the
federal investigators found in the unlicensed homes were: * A dirty, ramshackle house in which six elderly people depended on a small gas stove for heat. * A home in which an elderly resident, who needed to use a walker and lived on the third floor, was malnourished because he could not move fast enough to get downstairs in time for meals. * An elderly woman who was kept locked in a small room and would have perished in a fire.
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In interviews with the residents, investigators discovered that more than half the occupants of the boarding homes did not know the amount of their SSI checks. About twothirds said that they signed over their checks directly to operators. Congress has made only one effort to regulate boarding homes for the elderly. In 1976 it enacted Section 505(0) of the Social Security Act. Although calling on states to enforce standards for group living situations, the Act does not provide money to the states for this enforcement. The only penalty the Act provides for noncompliance with standards is a reduced SSI payment for the recipient in the boarding home. The GAO is urging all health care professionals to pressure their state governments into seeking promised assistance from the new GAO program in locating unlicensed boarding homes.
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NEWS WATCH
(oce,dure, Manual
Advisory Council Proposes Tax on Social .Security Benefits
A complete manual of all nursing procedures relevant to every health care faCility. Over five years of research in the latest procedures have resulted in this sturdy 10 % x 11 % book. More than 300 pages on how to best treat your patients, are bound in an attractive three ring binder. Save yourself and your staff hundred of hours. Separate pages allow you to modify any page to your health care facility procedure or add any procedures you think are important. No health care facility can afford not to have a copy of this important manual on their premises. No. 8300 ........... $33.00 ea. rJ."T:"Posey Co. - - - - - - - - - , 5635 Peck Rd. I Arcadia, CA 91006 I
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16 Geriatric Nursing May/June 1980
WASHINGTON, D.C.-A tax on half of all Social Security benefits that individuals receive has been called for by the Advisory Council on Social Security. This and other recommendations appeared in a 400-page report now under scrutiny by Congressional committees. The report suggests that an estimated 10.6 million Social Security beneficiaries pay an average of $350 yearly in taxes, and that the age for full retirement benefits be raised from 65 to 68. The report was prepared by a 12member panel of nongovernmental advisers that is responsible for changes in the Social Security system every four years. In the past the council has been highly influential in determining policy. The suggested changes are seen by economic analysts within the Department of Health and Human Services (formerly HEW) as a device to reduce the Social Security tax that is levied on 'workers' and on employers. The Advisory Council asserts that the current payroll tax hits lowincome persons proportionately harder than high-income individuals. However, three council members responded with "no comment" when GN asked them how the elderly poor, who comprise the lowest income group in the United States, could afford the tax that is proposed on SSI benefits. At present, Social Security payments enable elderly persons with no other income to live at 74.7 percent of the Federal poverty level, according to Social Security Administration statistics. Thirty-six percent of the elderly in the U.S live below the poverty level. Of this group, 20 percent are the 'heads of households whose annual income amounts to less than $3,000. Approximately 13.6 million persons receiving Social Security benefits would be exempt from the tax because of insufficient income, due to a provision in the council report. A
spokesman for the Social Security Administration, however, called this provision "impractical, considering the cuts in payroll taxes suggested by the council."
Announcements The ANA Council of Nursing Home Nurses will sponsor a program, "Health Assessment of the Institutionalized Elderly," at the American Nurses Association Convention to be held in Houston, Tex., June 8-13. The program, scheduled for June 9, is to be repeated on the 10th. Application for approval of contact hours . has been made. The Division on Gerontological Nursing Practice is offering two other programs during the convention: "Supporting Nursing Services," and "Health Behaviors: the Gerontological Nurse's Role." A new gerontology program has been announced by the University of San Francisco. Beginning this spring, USF liberal arts and science majors and graduate students may enroll in a 21-unit gerontological studies program that offers a certificate. upon graduation. The new program is expected to have 100 students within the next five years. For further information, write: USF Campus, Harney Science Center, Room 236, San Francisco, CA 94117 or call (415) 666-6373. The National Institute on Aging is accepting grant applications for social and behavioral research programs. Applications will be reviewed for projects to strengthen the scientific basis for professional practice and public policy in aging. For information write to: Social and Behavioral Research, NIA, 9000 Rockville Pike, Bldg. 31, Room 5C27, Bethesda, MD 20205. . C~ss IScountmg on you. . ,
credited skilled nursing facility. • Elimination of all proposed federally funded home health care demWHERE THE AXE WILL FALL onstration projects that were to have WASHINGTON, D.C.-President program for the aged and the elderly been sponsored by the Health SerCarter has proposed substantial cut- handicapped. vices Administration. backs in federally assisted programs • $70 million from rehabilitation Since the announcement of the for the aged in his fiscal 1981 loans to assist communities in subsi- Carter budget, key members of Conbudget. dizing physical rehabilitation pro- gress have called for additional cut"Restrictive" was the word James grams for the aged. backs in social services, to curb inflaT. McIntyre, director of the Presi• $20 million from Medicare for tion. Chairperson of the Senate Agdent's Office of Management and ing Committee, Lawton Chiles (D.Budget, used to describe the Fla.), supported further reducCarter proposals. tions. in human services as "a In an interview with GN, necessary means of stemming McIntyre said that "although inflation." the budget plans an overall inThe House Budget Commitcrease of approximately 4 pertee has already taken the first cent for programs for the elderstep toward trimming federal ly, the inflationary rate makes expenditures by endorsing cuts the 1981 outlays considerably of $ 15.9 billion in. the budget. lower than federal spending for that Mr. Carter submitted. the aged in 1980." Most of those reductions will The administration projects come from substantial reducmajor increases in federal revetions in social programs. nues that will reach over $600 Rural housing programs for billion in 1981.Military spendthe elderly poor were particuing is scheduled to increase larly hard hit by Housing and over 7 percent this year. In Urban Development's request . comparison to these increases, for the construction of only current programs to assist the 10,000 new housing units for Pnsidmt Carter: Cutbacks in services for the elderly will be cut and virtually the aged poor during 1981. no new programs are slated to be aged are "unfOl1Unste." White House officials confirm launched. that the President is considering reMedicare and Medicaid will re- the reimbursement of nursing costs moving the housing factor from the ceive overall increases of 4 percent of elderly patients awaiting transfer consumer price index. The housing and 3713 percent, respectively, during from an acute care hospital to an accost factor is a key figure that deter1981. However, the inflationary rate mines the annual cost of living adis projected by government econo- As GN went to press justments for S.S.I. recipients. mists to reach·if not exceed 20 perThe federal food stamp program A YOW to fight cutbacks in services will be discontinued for. June and. . for· the aged has been made by or. cent in the coming year. Among. specific budget cuts are: July due to lack of funds, the I;>ept. ganizations that advocate rights for • New limits. on reimbursement of agriculture announced on April the elderly. Leslie Kwass, chairperfor hospital costs that will cut $125 17. Three bills to provide an addi- son of the Gray Panther National million from Medicare.' tional $2.65 billion for the program Steering Committee, told GN, • An end to payment of the nurs- are before Congress. The federal "Those hurt most by cutbacks are ing cost differential for care of Med- government must notify each state of the elderly poor who, unlike the aged icare patients. Proposed cut-$191 its authority to distribute stamps for as a group, do not Yote and suffer million. the month of June by May 15. House from this lack of representation." • '$1.5 million slashed from funds Agriculture Committee members do A White House press officer acslated by the Office of Human De- not believe passage of the necessary knowledged in an interview with GN velopment Services for research appropriation bills is possible before that Mr. Carter's budget cuts would the end of July. Approximately 20 inevitably adversely affect the elderprojects on the needs of the elderly. • $9 million from Housing and million persons in the U.S. presently ly, but added that the President reUrban Development's assistance ,--r_e_ce_i_v_e_~_Ood __s_ta_m......:..p_s._· ---J gretted this as "unfortunate."
6 Geriatric Nursing May/June 1980
The 'Medigap' Scandal Abuses in the Sale of Supplementary Health Insurance to the Aged Two-thirds of all Americans over age 65, approximately 15 million people, own at least one "medigap" supplementary health insurance policy. The overwhelming majority of them have been sold inadequate coverage, and many are being defrauded. A two-year study by the House Select Committee on Aging has found widespread abuses in the sale of health insurance that supplements Medicare. Committee News chairperson Claude Pepper Close-up (D.-Fla.) estimates that . the elderly may be spending as much as $1 billion a year for worthless insurance policies purchased to pay the medical bills that Medicare does not reimburse them for. Medicare now pays less than 38 percent of health care costs, according to U.S. Dept. of Health and Hu-
man Services statistics. In order to protect themselves against financial ruin in the event of major illness, the elderly purchase medicare supplement or "medigap" policies. The enormous variety of policies and lack of consumer information make it extremely difficult to choose coverage that is adequate and economical, a 1978 Federal Trade Commission staff report concluded. Investigators for the Pepper committee discovered how vulnerable the elderly are to friendly young insurance agents who use high pressure sales techniques. Many aged persons are lonely, weak, and frightened. The salesman may be one of their few visitors, or their only visitor. The results are horrendous. For example: • An 80-year-old Pennsylvania woman spent over $50,000 on 31 policies over a three-year period. She took out a $3,000 bank loan to help make payments. • An 87-year-old Wisconsin woman purchased 19 different policies, which cost $4,000, from six agents representing nine companies. Most of her policies, like the others listed
here, were worthless because of duplication. • An Illinois woman was induced to mortgage her farm to buy 71 policies, most of them since 1976. • An 84-year-old Texas woman paid over S15,303 for 23 policies. Investigation revealed that among the items she was led into believing were insurance policies were several worthless vehicle warranty contracts and a deed to valueless Texas land. Just what techniques do salesmen use to deceive their clients? Former medigap agents have told GN about a number of practices they say are common: • Using brochures that describe fictitious coverage. • Advising elderly clients who already have insurance to let their present policies lapse and buy new, more expensive, and supposedly better policies. The agent receives a commission on the new policy. • Passing the names of particularly vulnerable and often seriously ill persons from agent to agent. In the industry slang these persons are called "crippies." Sometimes a group of salesmen
This U.S. Government hidden·camera photograph shows two senior citizen volunteers being persuaded to drop their existing coverage and buy more expensive policies, which are inadequate. (L to R) Volunteera Elizabeth Deitelhoff and Margaret Dickson, Pioneer Insurance agent William Gibson, and committee investigator David Holton (who posed aa a Pioneer trainee).
Geriatric Nursing May/June 19807
ELASf!> OINTMENT (fibrinolysin and desoxyribonuclease. combined [bovine!. ointment) DESCRIPTION. Elase Ointment is a combination 01 two lytic enzymes. fibrinolysin and desoxyribonuclease. supplied in an ointment base of liquid petrolatum and polyethylene. The fibrinolysin component is derived from bovine plasma and the desoxynbonuclease is isolated in a punfled form from bovine pancreas. The fibrinolysin used in the combination is activated by chloroform. ACTION. Combination of these two enzymes is based on the observation that purutent exudates consist largely of fibrinous material and nucleoprotein. Oesoxyribonu- . clease allacks the desoxynbonucleic acid (DNA) and fi· brinolysin attacks pnncipally "brin of blood clots and fibrinous exudates. The activity of desoxyribonuclease is limited principally to the produchon of large polynucleolides. which are less likely to be absorbed lhan the more dIffusible protein fractions tiberated by certain enzyme prepara· lions Obtained from bacleria. The fibrinolytic action 01 the enzymes in Elase Ointment is directed mainly against denatured proteins. such as those found in deVitalized tissue. while protein elements of living cells remain relatively unaffected. Elase Ointment is a combination of activ~ enzymes. This is an important consideration in treating patients suffenng from lesions resulling from impaired circulation The enzymatic action of Elase helps 10 produce clean surfaces and thuS supports healing in a variety ot exudative lesions. INDICATIONS. Etase Ointment is indIcaled for topical use as a debriding agent In a variety of inflammatory and infected lesions. These include: (1) generat surgical wounds; (2) ulcerative lesions-trophic. decubitus. stasis. arteriosclerotic; (3) second- and third-degree burns: (4) circumcision and episiotomy. Elase is used in· travaginally in: (1) cervicItis-benign. postpartum. and postconizatlon. and (2) vaginitis. PRECAUTIONS. The usual precautions against allergic reactions should be observed. particularly in persons with a history of sensitivity to materials of bovine origin or to mercury compounds. . ADVERSE REACTIONS. Side effects auributable to the enzymes have nOI been a problem at the dose and for the indications recommended herein. With higher con· cenuations. side effects have been minimal. consisting 01 local hyperemia. Chills and fever allributable to antigenic action of profibnnolysin activators of bacterial origin are not a problem with Elase. DOSAGE AND ADIIIINISTRATION. Since the condItions for which Elase Ointment is helpful vary considerably in seventy. dosage must be adjusted to the individual case; however. (he tollowing general recommendations can be made: Successlul use of enzymatic debridement depends on several factors: (I) dense. dry eschar. if present. should be removed surgically before enzymatic debridement is attempted: (2) the enzyme must be in constant contact with the substrate; (3) accumulated necrotic debris must be periodically removed; (4) the enzyme must be replenished at least once daily; and (5) secondary closure or skin grafting must be emplOyed as soon as possibte after optimal debridement has been attained It is further essentiat that ,",-ound-dressing techniques be performed carefUlly under aseptic conditions and thaI appropnate systemically acting antibiotics be administered concomitantly if. in the opinion Of the physician. they are indicated. General Topic:al Uses: Local application should be repeated at intervals for as long as enzyme action is de· sired. Alter application. Elase Ointment becomes rapidly and progressively less active and is probably exhausted for pracllcal purposes at the end of 24 hours. Infray_ginal Use: In milclto moderate vaginitiS and cerviCItis. 5 mt of Elase Ointment should be deposited deep in the vagina once nightly at bedtime for approximately five applications, or until the entire contents of one 30 g tube has been used. The patient should be checked by her physician to determIne possible need for further therapy. In mOte severe cervicitis and vaginitis. Some physiCIans prefer to initiate therapy With an application of Elase ('Ibrinolysin and desoxynoonuclease. combined [bovine]) in sOlut,on. See Elase package insert. HOW SUPPLIED. N 0071-4279-13 Elase Ointment. 30 g. The 30 g tube contains 30 units of fibrinolySin and 20.000 units of desoxyribonuclease With 0.12 mg thimerosal (mercury derivative) in a special ointment base of hQuid petrolatum and polyelhylene. NOQ71·4279·10ElaseOlnlmenl. 109 The 109 tube contains 10 units Of "brinolYSln and 6_666 units of desoxynbonuclease with 0 04 109 thimerosal (mercury derivative) In a special ointment base of liquid petrolatum and polyelhylene ThIS product also conla:ns sod!um Chloride and sucrose as Jncld~ntallngredlents YO
PARKE-DAVIS
Div 01 Warner-Lambert Co Morris Plains. NJ 07950 USA
10 Gerialric
Nursing
May/June
1980
NEWS WATCH visit an old person and psychologically intimidate him. Other agents simply forge client signatures. Roger Deneberg, former head of the Federal Trade Commission,. told GN that "mil1ion dollar advertising campaigns are used by companies , that specialize in mail order medigap insurance.
"Popular personalities seen on TV sel1ing medigap insurance are generally selling inadequate insurance. "Most of these policies offer indemnity benefits that pay cash directly to the insured person. The payments are usually based on the number of days spent in a hospital, with maximum payments of $400 to
Percentage of Medigap Insurance Premiums Returned to The Insured in the ronn of Oaims *(Selected Companies) The "loss ratio" 01 an insurance policy is the percentage 01 premium payment returned to the insured. A medigap policy that pays you 50¢ for each dollar you spend in premiums has a loss ratio of 50%.
--=-10OJo 20% 30% 40% 50% 60010 70% 80% 90% 100%
.;:Co=m:!:p=an:.::y~
Mutual Protective Ins. Medico Life MONY New York Life American United Life National Casualty Co. American Progressive National Security InS. Reliable Constitution Life Old American Pioneer Life of Illinois Liberty National Life Pacific Mutual Businessmen's
~urance
American Exchange Life Commercial State Life Union Bankers Country Life Aid to Lutherans All American Casualty CONA Bankers Life and Casualty Guarantee Reserve Life American National American Variable Annuity Chesapeake Life Guardian Rural Mutual Mutual Benefit Life Banker's (Iowa) Home Life ·Source: House Select Commiltcc on Aging, 1979.
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Caplow·Lindnc:r, Erna, M.S. Luh Harpaz, M.A. Sonya Sambc:rg, G.D.T.
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12 G.,riatric Nursing May/June 1980
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$800 or possibly $1,000 a month. That may sound like a lot," Deneberg said, "but even $1,000 a month provides only $33.33 a day-far be. low current daily hospital costs and far less coverage than aged individuals should have." The Senate Committee on Aging estimates that the average senior citizen spends more than $200 a year on medigap coverage but receives an average of less than $85 a year in claims. Medigap policies pay approximately 5 percent of the health bill of the aged. Elderly Americans now pay more of their money for physician services, hospital care, and drugs than they paid before Medicare was enacted in 1966, reports the General Accounting Office. . Of more than 60 medigap policies scrutinized by the House Select Committee on Aging, fewer than 15 provided adequate coverage. But even with Medicare and the best private insurance, individuals over 65 spent an average of more than $500 for health care in 1979. Many gaps left by Medicare are not covered by any private policy. Charges for routine physical exams, medical appliances, out-of-hospital prescription drugs, dental care, and eyeglasses, for example, are billable only to the patient. Perhaps the most critical category of coverage for many of the aged is nursing home care. Medicare pays nursing home bills only when a long list of conditions are met; among them: the nursing home must be certified by Medicare; the patient's nursing home stay must follow a hospital stay of at least three days; and the patient must receive skilled nursing, not custodial care. If these and other preconditions are met, Medicare pays for the first 20 days of the nursing home stay. It also pays for days 21 to 100, except for a copayment by the patient of $20 a day. After 100 days the patient gets nothing. Private medigap insurers offer little to compensate for these serious inadequacies. Medicaid is available, but as most of the elderly know, it is a welfare. program and is available only to those living below the poverty level. In the U.S., one out of four people
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14 Geriatric Nursing May/June 1980
over 65 technically qualify for Medicaid. Are all medigap policies fraudulent? Experts say no. Numerous studies, including the House Aging Committee report, indicate that a person is best off if he or she maintains his group policy after retirement or joins a Health Maintenance Organization. If one must purchase a private policy, it is well to remember that Blue Cross/Blue Shield has been consistently awarded top marks by state and federal commissions for its medigap insurance. Several commercial insurance policies sold to individuals offer satisfactory coverage, but most do not. The elderly should be particularly careful to examine policies sold through private organizations and clubs. The outlook for legislative reform to correct the abuses in the sale of health insurance to supplement Medicare is not promising. At present, private insurance companies are not obligated to register or be certified by state or federal government. Section 508 (a) of the Social Security Act of 1979 provides that a procedure for voluntary certification be set by July 1, 1981. Even at that time, however, private companies will not be required by law to meet minimum standards with respect to adequacy of coverage, oversight of premium charge, and disclosure of information to the insured. The Senate has recently passed an amendment to H.R. 3236, The Social Security Disability Amendment of 1979, that encourages but does not force states to implement regulatory policies on the sale of medigap insurance. If individual states do not act by Jan. 1, 1982, the federal government is given authority to certify medigap insurance companies if the companies take the iniative and voluntarily request to be certified. Claude Pepper, who terms medigap insurance "a tragic national scandal," had proposed similar legislation in the form of H.R. 2602, a bill devoted to regulating medigap insurance companies. This legislation has also recently been passed by the Senate, but like the Chiles amendment, the bill calls for only voluntary certification.
Financially Troubled Nursing Homes Aided by Suspension of State Reimbursement Limit WASHINGTON, D.C.-Financially troubled nursing homes nationwide will be aided by a new federal ruling that will raise the limits placed on reimbursements paid to long-term care facilities. The Department of Health and Human Services (formerly HEW) announced in the Federal Register the suspension of a ruling that limits state reimbursement rates for all long-term care facilities to the same amount paid by Medicare. The suspension will indirectly increase federal and state payments to homes and will cost both the federal and state governments an additional $17 million each in 1981. The ruling, however, will allow many bankrupt homes to remain in operation. Ninety of the 790 nursing homes in New York State alone would have had to close their doors without the additional revenue. The action follows a temporary restraining order obtained by the New York Association' of Homes for the .Aged against a Health Care Financing Administration (HCFA) regulation that instituted reimbursement ceilings. In a related move, HHS has asked for public comment on its proposal to place Medicare cost ceilings on state' programs. The states of New York, Connecticut, Michigan, and Wisconsin have nursing home rates approved by Health and Human Services that are set higher than the limits on Medicare Reimbursement. If the proposal becomes law, industry analysts anticipate further problems for large, for-profit nursing homes. Commercial nursing homes nationwide have faced serious cash flow problems in the last decade. "Although we remain committed to keeping nursing home costs within reasonable limits," HHS Secretary Patricia Harris explained in an interview, "we do not want to penalize facilities or individual states if there is real justification for higher reimbursement rates.' "
GAO Computer Method Locates Unlicensed Boarding Homes Health Professionals Urged To Seek Implementation WASHINGTON,O.C.-Newhopes of locating the abused elderly in unlicensed boarding homes have been raised by a computer method recently devised by the General Accounting Office. The development of the computerized data retrieval process was announced by GAO in a special report to Congress: When applied to Social Security Administration records, the new system can' identify addresses to which more than three Social Security checks are sent each month. The nationwide problem of exploitative boarding homes for the elderly arose, according to the report, as a result of the government policy to deinstitutionalize the elderly and the start-up in 1974 of Supplementary Social Security Income for the aged. This added income has enabled many aged persons to leave institutions but forced them to seek out low-cost group living arrangements. Hearings in 1977 before the House Select Committee on Aging, chaired by Rep. Claude Pepper (0.Fla.), revealed that many SSI recipients were endorsing their entire checks over to boarding home operators. The hearings also publicized widespread abuses in the homes. Individual states, which are responsible for enforcing standards in boarding homes, were often not able to locate them. Rep. Pepper says that more than 75 lives were lost in these unlicensed homes in 1979 alone in fires. In im initial test, the GAO used Social Security records to locate addresses in Baltimore, Md., and Camden, N.J., where three or more checks were sent each month. After eliminating family groups and institutions, the GAO sent investigators to 38 of the addresses. Ten of the boarding homes were unknown to state officials.Among the conditions that the
federal investigators found in the unlicensed homes were: * A dirty, ramshackle house in which six elderly people depended on a small gas stove for heat. * A home in which an elderly resident, who needed to use a walker and lived on the third floor, was malnourished because he could not move fast enough to get downstairs in time for meals. * An elderly woman who was kept locked in a small room and would have perished in a fire.
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In interviews with the residents, investigators discovered that more than half the occupants of the boarding homes did not know the amount of their SSI checks. About twothirds said that they signed over their checks directly to operators. Congress has made only one effort to regulate boarding homes for the elderly. In 1976 it enacted Section 505(0) of the Social Security Act. Although calling on states to enforce standards for group living situations, the Act does not provide money to the states for this enforcement. The only penalty the Act provides for noncompliance with standards is a reduced SSI payment for the recipient in the boarding home. The GAO is urging all health care professionals to pressure their state governments into seeking promised assistance from the new GAO program in locating unlicensed boarding homes.
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(oce,dure, Manual
Advisory Council Proposes Tax on Social .Security Benefits
A complete manual of all nursing procedures relevant to every health care faCility. Over five years of research in the latest procedures have resulted in this sturdy 10 % x 11 % book. More than 300 pages on how to best treat your patients, are bound in an attractive three ring binder. Save yourself and your staff hundred of hours. Separate pages allow you to modify any page to your health care facility procedure or add any procedures you think are important. No health care facility can afford not to have a copy of this important manual on their premises. No. 8300 ........... $33.00 ea. rJ."T:"Posey Co. - - - - - - - - - , 5635 Peck Rd. I Arcadia, CA 91006 I
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16 Geriatric Nursing May/June 1980
WASHINGTON, D.C.-A tax on half of all Social Security benefits that individuals receive has been called for by the Advisory Council on Social Security. This and other recommendations appeared in a 400-page report now under scrutiny by Congressional committees. The report suggests that an estimated 10.6 million Social Security beneficiaries pay an average of $350 yearly in taxes, and that the age for full retirement benefits be raised from 65 to 68. The report was prepared by a 12member panel of nongovernmental advisers that is responsible for changes in the Social Security system every four years. In the past the council has been highly influential in determining policy. The suggested changes are seen by economic analysts within the Department of Health and Human Services (formerly HEW) as a device to reduce the Social Security tax that is levied on 'workers' and on employers. The Advisory Council asserts that the current payroll tax hits lowincome persons proportionately harder than high-income individuals. However, three council members responded with "no comment" when GN asked them how the elderly poor, who comprise the lowest income group in the United States, could afford the tax that is proposed on SSI benefits. At present, Social Security payments enable elderly persons with no other income to live at 74.7 percent of the Federal poverty level, according to Social Security Administration statistics. Thirty-six percent of the elderly in the U.S live below the poverty level. Of this group, 20 percent are the 'heads of households whose annual income amounts to less than $3,000. Approximately 13.6 million persons receiving Social Security benefits would be exempt from the tax because of insufficient income, due to a provision in the council report. A
spokesman for the Social Security Administration, however, called this provision "impractical, considering the cuts in payroll taxes suggested by the council."
Announcements The ANA Council of Nursing Home Nurses will sponsor a program, "Health Assessment of the Institutionalized Elderly," at the American Nurses Association Convention to be held in Houston, Tex., June 8-13. The program, scheduled for June 9, is to be repeated on the 10th. Application for approval of contact hours . has been made. The Division on Gerontological Nursing Practice is offering two other programs during the convention: "Supporting Nursing Services," and "Health Behaviors: the Gerontological Nurse's Role." A new gerontology program has been announced by the University of San Francisco. Beginning this spring, USF liberal arts and science majors and graduate students may enroll in a 21-unit gerontological studies program that offers a certificate. upon graduation. The new program is expected to have 100 students within the next five years. For further information, write: USF Campus, Harney Science Center, Room 236, San Francisco, CA 94117 or call (415) 666-6373. The National Institute on Aging is accepting grant applications for social and behavioral research programs. Applications will be reviewed for projects to strengthen the scientific basis for professional practice and public policy in aging. For information write to: Social and Behavioral Research, NIA, 9000 Rockville Pike, Bldg. 31, Room 5C27, Bethesda, MD 20205. . C~ss IScountmg on you. . ,