It goes without saying that long term care providers are allowed to administer drugs to patients, and extra care is required when acquiring, receiving, dispensing and administering foreign prescription drugs.

The attached letter (PDF) instructs state survey agency directors on what to do when providers administer foreign drugs. Foreign drugs that purport to be the same as Food and Drug Administration-approved drugs may be substandard and/or dangerous. Providers must make sure that foreign prescription drugs are approved by the FDA and meet U.S. labeling requirements.

Long term care provider facilities administering imported drugs must comply with 42 C.F.R. 483.60 (a). State surveyors certainly have their jobs cut out for them, so providers should do their part by dealing with manufacturers or distributors that comply with the Federal Food, Drug, and Cosmetic Act instead of importing drugs directly from foreign entities.

Many Medicare beneficiaries are elderly and most of them will likely have trouble understanding the complicated new drug plan because of age-related cognitive impairments. As a result, long term care providers will need to educate patients about the new plan, which some predict will prove burdensome.

Several long term care association members expressed their concerns in this Dallas Morning News article (free registration):

The American Health Care Association, which represents long-term care providers, says it understands the rule’s rationale but worries about how to educate residents on the plans.

“We know we can’t steer anyone to a plan, but many of our patients are old and frail,” said association spokeswoman Susan Feeney. “Lawmakers didn’t consider that in crafting the law.”

The typical nursing home resident is 84 and takes nine medications, according to the Long Term Care Pharmacy Alliance.

Stephen Cutshaw, an administrator at the C.C. Young retirement community in Dallas, said he and his staff are working with patients’ families to explain the new Medicare benefit.

“It’s been burdensome to implement,” he said. “We can sit down with them and explain their options. But we have to stand back when it comes time for them to make a decision.”

There seems to be a growing consensus that the new drug plan is confusing. Whether Medicare will simplify the program remains to be seen.

This story was sent to PPAT by one of the members. Carole at PPAT gave me permission to post it here.

I try not to be biased, but I had my doubts about hiring Stevie. His placement counselor assured me that he would be a good, reliable busboy. But I had never had a mentally handicapped employee and wasn’t sure I wanted one. I wasn’t sure how my customers would react to Stevie. He was short, a little dumpy with the smooth facial features and thick-tongued speech of Downs Syndrome. I wasn’t worried about most of my trucker customers because truckers don’t generally care who buses tables as long as the meatloaf platter is good and the pies are homemade. The four-wheeler drivers were the ones who concerned me; the mouthy college kids traveling to school; the yuppie snobs who secretly polish their silverware with their napkins for fear of catching some dreaded “truck stop germ” the pairs of white-shirted business men on expense accounts who think every truck stop waitress wants to be flirted with. I knew those people would be uncomfortable around Stevie so I closely watched him for the first few weeks.

I shouldn’t have worried. After the first week, Stevie had my staff wrapped around his stubby little finger, and within a month my truck regulars had adopted him as their official truck stop mascot.

After that, I really didn’t care what the rest of the customers thought of him. He was like a 21-year-old in blue jeans and Nikes, eager to laugh and eager to please, but fierce in his attention to his duties. Every salt and pepper shaker was exactly in its place, not a bread crumb or coffee spill was visible when Stevie got done with the table.

Our only problem was persuading him to wait to clean a table until after the customers were finished. He would hover in the background, shifting his weight from one foot to the other, scanning the dining room until a table was empty. Then he would scurry to the empty table and carefully bus dishes and glasses onto cart and meticulously wipe the table up with a practiced flourish of his rag. If he thought a customer was watching, his brow would pucker with added concentration. He took pride in doing his job exactly right, and you had to love how hard he tried to please each and every person he met.

Over time, we learned that he lived with his mother, a widow who was disabled after repeated surgeries for cancer. They lived on their Social Security benefits in public housing two miles from the truck stop. Their social worker, who stopped to check on him every so often, admitted they had fallen between the cracks. Money was tight, and what I paid him was probably the difference between them being able to live together and Stevie being sent to a group home. That’s why the restaurant was a gloomy place that morning last August, the first morning in three years that Stevie missed work.

He was at the Mayo Clinic in Rochester getting a new valve or something put in his heart. His social worker said that people with Downs Syndrome often have heart problems at an early age so this wasn’t unexpected, and there was a good chance he would come through the surgery in good shape and be back at work in a few months.

A ripple of excitement ran through the staff later that morning when word came that he was out of surgery, in recovery, and doing fine. Frannie, the head waitress, let out a war hoop and did a little dance in the aisle when she heard the good news. Belle Ringer, one of our regular trucker customers, stared at the sight of this 50-year-old grandmother of four doing a victory shimmy beside his table. Frannie blushed, smoothed her apron and shot Belle Ringer a withering look.

He grinned. “OK, Frannie, what was that all about?” he asked.

“We just got word that Stevie is out of surgery and going to be okay.”

“I was wondering where he was. I had a new joke to tell him. What was the surgery about?”

Frannie quickly told Belle Ringer and the other two drivers sitting at his booth about Stevie’s surgery, then sighed: “Yeah, I’m glad he is going to be OK,” she said. “But I don’t know how he and his Mom are going to handle all the bills. From what I hear, they’re barely getting by as it is.” Belle Ringer nodded thoughtfully, and Frannie hurried off to wait on the rest of her tables.

Since I hadn’t had time to round up a busboy to replace Stevie and really didn’t want to replace him, the girls were busing their own tables that day until we decided what to do. After the morning rush, Frannie walked into my office. She had a couple of paper napkins in her hand and a funny look on her face.

“What’s up?” I asked.

“I didn’t get that table where Belle Ringer and his friends were sitting cleared off after they left, and Pony Pete and Tony Tipper were sitting there when I got back to clean it off,” she said. “This was folded and tucked under a coffee cup.” She handed the napkin to me, and three $20 bills fell onto my desk when I opened it. On the outside, in big, bold letters, was printed “Something For Stevie. Pony Pete asked me what that was all about,” she said, “so I told him about Stevie and his Mom and everything, and Pete looked at Tony and Tony looked at Pete, and they ended up giving me this.” She handed me another paper napkin that had “Something For Stevie” scrawled on its outside. Two $50 bills were tucked within its folds. Frannie looked at me with wet, shiny eyes, shook her head and said simply: “truckers.”

That was three months ago. Today is Thanksgiving, the first day Stevie is supposed to be back to work. His placement worker said he’s been counting the days until the doctor said he could work, and it didn’t matter at all that it was a holiday. He called 10 times in the past week, making sure we knew he was coming, fearful that we had forgotten him or that his job was in jeopardy. I arranged to have his mother bring him to work. I then met them in the parking lot and invited them both to celebrate his day back. Stevie was thinner and paler, but couldn’t stop grinning as he pushed through the doors and headed for the back room where his apron and busing cart were waiting.

“Hold up there, Stevie, not so fast,” I said. I took him and his mother by their arms. “Work can wait for a minute. To celebrate you coming back, breakfast for you and your mother is on me!”

I led them toward a large corner booth at the rear of the room. I could feel and hear the rest of the staff following behind as we marched through the dining room. Glancing over my shoulder, I saw booth after booth of grinning truckers empty and join the procession. We stopped in front of the big table. Its surface was covered with coffee cups, saucers and dinner plates, all sitting slightly crooked on dozens of folded paper napkins.
“First thing you have to do, Stevie, is clean up this mess,” I said. I tried to sound stern. Stevie looked at me, and then at his mother, then pulled out one of the napkins. It had “Something for Stevie” printed on the outside. As he picked it up, two $10 bills fell onto the table.

Stevie stared at the money, then at all the napkins peeking from beneath the tableware, each with his name printed or scrawled on it. I turned to his mother.

“There’s more than $10,000 in cash and checks on table, all from truckers and trucking companies that heard about your problems. “Happy Thanksgiving,”

Well, it got real noisy about that time, with everybody hollering and shouting, and there were a few tears, as well. But you know what’s funny? While everybody else was busy shaking hands and hugging each other, Stevie, with a big, big smile on his face, was busy clearing all the cups and dishes from the table. Best worker I ever hired.

Plant a seed and watch it grow. At this point, you can bury this inspirational message or forward it fulfilling the need! If you shed a tear, hug yourself, because you are a compassionate person.

Under Medicare’s new prescription drug plan, which goes into effect in January 2006, beneficiaries will have to choose between the new plan and free meds offered by private drug companies. These and other aspects of the program are causing confusion among seniors and industry experts.

For example, the program won’t be administered by the Social Security Administration, which oversees hospitalization and doctors fees under Medicare. Private insurance companies will manage the plan. Implications?

This shift means that seniors must choose between drug plans with widely differing premiums, deductibles, co-payments and covered drugs. In Kansas, for example, Medicare beneficiaries have to shop for insurance among 40 plans from insurers such as Aetna, Humana and UnitedHealth Group, which charge premiums from $9.48 a month to $67.88 a month. (Medical News Today)

Why is the new plan so confusing? When companies are allowed to compete for consumers, product choices abound. With a decentralized program, private companies can offer a wider variety of drug plans, which can become difficult to manage.

Last week the Philadelphia Inquirer examined drug companies that plan to eliminate charitable prescription drug programs in light of Medicare’s new plan. The drug industry gave away about $4.1 billion in prescription drugs last year, but millions of beneficiaries will no longer be able to obtain these drugs and stay with Medicare’s program after January 2006.

Medical News Today is an excellent resource for links and in-depth coverage of reactions to the new plan.

Earlier this month I wrote that the Senate Finance Committee approved a bill that would reduce Medicare and Medicaid spending by $10 billion over five years. The full Senate approved the bill on November 4, 2005, and the House of Representatives recently passed its version of the bill, which would cut Medicaid funding by $12 billion over five years.

If both chambers of Congress approve the House version of the bill, expect the following changes:

• Medicaid co-payments may rise with inflation;
• People with home equity of $750,000 or higher would be denied long-term care coverage;
• States may impose new costs on beneficiaries and scale back coverage;
• Pharmacies would be encouraged to sell generic drugs, and payments to pharmacies would be reduced. (Medical News Today)

As expected, the vote was divided along party lines, with the bill passing by a mere two votes. From the Dallas Morning News (free reg. req.):

“Our children will drown in a sea of debt or a sea of taxes if we don’t reform these entitlement programs,” said Rep. Jeb Hensarling, R-Dallas, a leader among House conservatives pushing for budget cuts. “Food stamps will be up. Medicare will be up. Medicaid will be up. … Last I looked in Webster’s dictionary, ‘cut’ means to reduce.”

But Democrats and advocates for the poor characterized the spending shifts as real cuts with real consequences.

The nonpartisan Congressional Budget Office projected that 300,000 people would lose food stamps under the House GOP plan….That includes at least 36,000 in Texas. And the state would lose more than $900 million in Medicaid funds over the five years.

The Centers for Medicare and Medicaid Services (CMS) has announced that Medicare payments to home health agencies will increase by 2.8 percent next year. Home health care providers, paid through a prospective payment system, can expect $370 million in payments in 2006.

How are payment rates calculated? From the CMS web site:

Home health payment rates are updated annually by either the full home health market basket percentage, or by the home health market basket percentage as adjusted by Congress. CMS establishes the home health market basket index, which measures inflation in the prices of an appropriate mix of goods and services included in home health services. For CY 2006, the home health market basket percentage is 3.6. Section 701(b)(4) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 provided that updates for CY 2005 and CY 2006 will equal the applicable home health market basket percentage increase minus 0.8 percentage point.

A few days ago I wrote about the Senate’s budget bill, which will reduce Medicare and Medicaid spending by $10 billion over five years. According to Medical News Today, the bill will also eliminate Medicare beneficiaries’ choice of continuing to rent medical equipment in the capped rental category because a section of the legislation would discontinue that option.

How does this effect providers? If Medicare beneficiaries have to pay to maintain the equipment, providers can no longer offer this service. The American Association for Homecare is asking providers to write their members in Congress urging them to retain the capped rental option.

If you have fruit trees on your premises, don’t let the fruit fall to the ground and ferment lest this happen:

They rarely have problems with drunks or rowdy animals, but residents of an elderly home in southern Sweden had to deal with both when a pair of intoxicated moose invaded the premises.

The moose _ a cow and her calf _ had become drunk over the weekend by eating fermented apples they found outside the home in Sibbhult, southern Sweden, said Anna Karlsson, who works there.

Read the rest of the story by clicking here.

Medicare beneficiaries may have to choose between the new prescription drug program or free medication from drug companies. I recently wrote about Medicare’s new prescription drug program, which goes into effect in January 2006.

From the New York Times (registration required):

Mr. Bach, 65, who is blind, received worrisome news last month from Bristol-Myers Squibb. The free Plavix he gets from the company’s charitable foundation will stop if he enrolls in the new Medicare prescription program that begins in January.

Mr. Bach says that his free Plavix, a $125-a-month blood thinner that reduces the risk of heart attacks and strokes, is more valuable than the immediate benefits he would receive from signing up for the Medicare program, even taking into account the three inexpensive generic drugs he also takes.

Why will patients have to choose? According to the story, some drug companies are eliminating free drug programs because recipients will be eligible for the new coverage under Medicare. How the unintended consequences of Medicare’s new drug program will effect providers remains to be seen.

November has been designated National Hospice Month. As more families continue to face difficult decisions about hospice care, providers have an opportunity to raise awareness about end-of-life issues for the terminally ill and their care-givers.

The National Association for Homecare and Hospice has written an informative fact sheet called Hospice Facts & Statistics (PDF).

I’m also linking to a letter to the editor at the Journal Standard written by a woman who works at a hospice called Odyssey Healthcare of Rockford. She writes:

Hospice care is based on the simple idea that a person is more than an illness. Each of us has unique physical, emotional and spiritual needs. Hospice places the highest value on respect, choice and empowerment for patients and their family members…

So what is hospice? It’s caring, loving people caring for others in a supportive, compassionate and respectful manner so the patient can be surrounded by family and loved ones, many times at home, pain-free. It’s good for the soul, the heart, the family and the patient.

I have previously written about the recent death of the founder of the modern hospice movement, Dame Cecily Saunders. Click here to read that post.