Starting today, a nursing home resident may opt out of physical therapy because she has exceeded Medicare’s payment limit. And a nursing home may deliver therapy knowing it will not get paid for it.

While such scenarios may seem a little extreme, that’s the plausible effect of Medicare Part B outpatient therapy caps, which take full effect today.

Most providers were caught off-guard a bit by the latest turn of events. The Senate was expected to pass a Medicare bill by the Fourth of July recess that would have reauthorized an exceptions process for the caps—but it didn’t act in time.

“I don’t think people expected it to end the way it did,” said Marsha Greenfield, senior legislative counsel for the American Association of Homes and Services for the Aging.

The last time providers experienced the cap was in 2006—prior to the onset of the exceptions process, which shielded residents from the caps and was retroactive to the beginning of the year. The caps also went into effect in 2003—and then only for three months. Prior to that, caps were in place in 1999.

For those who are not familiar with Part B outpatient therapy caps, the caps place annual limits on what Medicare will spend for outpatient therapy. They amount to $1,810 on speech and physical therapy combined and $1,810 on occupational therapy. To make matters worse, while the caps start today, they include any therapy that contributed to the limits starting back in January.

The caps were first introduced in the Balanced Budget Act of 1997 (back then, the caps were $900). Several moratoria, and most recently the exceptions process, however, have served to protect residents from the regulation.

Here’s a hypothetical situation of what the caps mean:

Harold, an 85-year-old, broke his hip in January and went to a nursing home for outpatient therapy for six to eight weeks. Total cost of the rehab? About $1,500. Just two weeks ago, Harold had a stroke. He needs more therapy, but he will soon exceed his limit. What does he do?

That is the $10,000 (er, $1,810) question—and the reason why providers have been fighting so hard against the 11-year-old policy.

Let’s hope that the Senate comes back from the Fourth of July refreshed and ready to again knock out the policy before it does any real damage.

Some people, and their groups, are better at furthering the art of tactless solicitation than others.

For the latest case of hoof-in-mouth disease, we only have to look to our friends at People for the Ethical Treatment of Animals, otherwise known as PETA (www.peta.org).

Seems someone in the PETA brain trust heard a lot of nursing home residents haven’t taken advantage of their opportunity to file for federal stimulus refund checks. That’s up to $600 each for thousands of people. That’s a lot of money.

So what did this august group’s leadership do? Like vultures they would surely seek to protect, they swooped down to see how much they could scrounge.

On Tuesday, PETA sent letters to the CEOs of the five of the nation’s seven largest nursing home chains, asking them to nudge residents into filing paperwork for their refunds. Then, the residents could turn around and give the money to PETA or some other “humane” charity. Outrageous.

What’s next? Shaking down single parents on welfare for “leftover” money? Coaxing soup kitchens to cut back on the noodles and broth to help fund the latest animal-related research?

While PETA lists other charities in the letter and offers a Web site of approved organizations, the site (caringconsumer.com) is sponsored and operated by … PETA.

Simply consider the priorities of PETA President Ingrid E. Newkirk in her formal nursing-home solicitation: “We’re asking that these nursing-home companies make a concerted effort to help their residents obtain their checks and urge their residents to use the money to help animals and others in need.”

The gall of asking for this one-time windfall from a population that is largely on Medicaid is almost unfathomable. To think that such people—who normally receive perhaps just $30 to $50 of personal money per month from Medicaid for everything they want—are being asked to start forking over the largest lump sum they’re bound to see for a while boggles the mind.

It doesn’t matter what your overall thoughts on PETA, animals, nursing homes, caregiving or general politics are. This attempted pimping of some of our nation’s most frail and elderly citizens should be shouted down, or at a bare minimum, coldly ignored.

So to the CEOs of HCR ManorCare, Kindred Healthcare, Genesis HealthCare, Golden Living and SavaSeniorCare (who normally need no help running their businesses), I say: Go ahead, urge your residents to file their paperwork and get what they have coming. Then leave them alone.

Or, to show the sensitive folks at PETA you haven’t forgotten them, encourage your residents to put their money toward a different kind of animal-related investment—like a nice, big steak and lobster dinner at the finest restaurant in town.

Yes, you too could be the Four Seasons of nursing homes.

As we all know by now, the Centers for Medicare & Medicaid Services plans to create a five-star quality rating system for facilities (see stories on the McKnight’s home page from Wednesday and Thursday). The system, whose metrics are still being refined, will appear on the consumer-oriented Nursing Home Compare Web site (www.Medicare.gov/NHCompare) by year’s end.

I don’t know about you, but the first thought that came to my mind when I heard about the plan was hotels. After all, when most of us choose accommodations we go to a Web site like Expedia.com or Travelocity.com to see first-hand visitors’ opinions. Will it be any different for nursing homes? You could either be a first-class, chocolate-on-the pillow type of joint, or a lowly two-star, where the pool is more of a pond?

But the comparison only goes so far. The reason is, and I hate to break it to everyone, but nursing homes aren’t hotels. They aren’t washing machines or any other kind of commodity that consumers judge by scores either.

Unlike those resorts in Puerto Vallarta, nursing homes aren’t taking care of honeymooners. Rather, the guests are vulnerable, high-acuity residents, and many don’t want to be there.

Granted, families want to know more about the nursing homes where they are sending their parents. And they should have as much information as possible. Transparency is a good thing. If you shop on Nursing Home Compare today you’ll learn a lot of objective information about a facility, such as its number of beds, the number of nurse staffing hours, and the results of its last survey, including details about deficiencies.

Adding a ratings system, while a customer-oriented measurement, may be setting consumers up for disappointment. A five-star nursing home, unlike its counterpart in the hospitality industry, will not have bronze beachcombers lounging by the pool. There likely will be a resident or two slumped in her chair when a visitor arrives, and there could be unpleasant sounds and smells wafting through the hallways.

But the ratings system isn’t necessarily a bad idea either—if nursing homes get their fair shake-such as figuring residents’ and families’ satisfaction scores into the mix.

And there could be upsides. How about this recommendation for CMS? More Medicare and Medicaid funding for five-star facilities.

Make that one for Sen. Charles Grassley. The usual thorn in the side of the nursing home industry likely won some points from this crowd this week after introducing a measure that would delay the new durable medical equipment competitive bidding process.

It was a smart move by the hard working, highly respected (and slightly irritable) senior Republican senator from Iowa.

The controversial policy, which is scheduled to start on July 1 in the first round of 10 metropolitan statistical areas, has provoked an outcry from durable medical equipment suppliers and nursing home providers alike. It was a major topic of discussion raised in providers’ meetings with lawmakers at last week’s American Health Care Association conference in Washington, D.C.

They have a right be upset.

While the process aims to cut the amount of money that Medicare spends on these goods, it rewards larger suppliers and edges out the smaller companies that many nursing homes rely on. (The bidding process affects durable medical equipment, such as walkers, wheelchairs and power scooters, as well as prosthetics, orthotics and supplies. These are referred to collectively as DMEPOS.)

Companies have argued that some favored bidders don’t necessarily know the business of some of the products in their contracts. Also, many facilities have had long-standing agreements with their suppliers and know they can obtain ordered equipment on short notice. Being given another supplier might mean a facility has to wait longer for a needed piece of equipment.

It is heartening that legislators are responding to their providers’ concerns. I can say with first-hand certainty that Sen. Blanche Lincoln (D-AR) was receptive to complaints regarding the policy from a delegation from Arkansas that came to pay her a visit at the AHCA conference last week.

Along with Grassley, Sen. Max Baucus (D-MT) introduced a bill delaying the process by 18 months. Both senators included their measures in larger Medicare legislation that would delay the Medicare physician payment cut.

Also, yesterday, Rep. Pete Stark (D-CA), chairman and ranking member of the House Ways and Means Health Subcommittee, introduced a bipartisan bill (H.R. 6252) that would delay and adjust the controversial program.

Lawmakers clearly are bi-partisan in their distaste for the bill. As Grassley’s action shows, it appears that adversaries can, from time to time, see eye to eye.

You’d think by the age of 93 you’d be ready to kick back, take stock of things and reminisce a little. Not Jack LaLanne. The so-called “Godfather of Fitness” is still going full-throttle.

“Everybody thinks about the good old days,” the former host of “The Jack LaLanne Show,” a TV exercise program, told me this week over the phone from his company in Morro Bay, CA. “The hell with the good old days! The good old days are right this second! Life’s exciting. Life’s wonderful. Life’s an athletic event!”

That has certainly been the case for LaLanne, who introduced weight lifting to the masses. The indomitable LaLanne has performed feats of strength since 1954. It was then, at the age of 40, that he swam the length of the Golden Gate Bridge in San Francisco, underwater, with 140 lbs. of equipment, including two air tanks. Other acts of physical fortitude included swimming handcuffed from Alcatraz to Fisherman’s Wharf and setting a world record of 1,033 push-ups in 23 minutes on TV.

For his 95th birthday in 2009, LaLanne, who has a star on the Hollywood Walk of Fame, hopes to swim 20 miles to Santa Catalina Island from the California coast.

He does these stunts, he said, to prove his philosophy regarding the importance of eating well and exercising, a concept that was, ironically, considered somewhat unhealthy back in the 1930s and 40s. (Encouraging women to lift weights? Egads!)

“Everything, I had to do, I had to prove it,” said LaLanne who prides himself on a diet of raw vegetables, whole grains, brown rice, and only all-natural, fresh everything else. “On my 70th birthday, I towed 70 boats. (People think) this guy must be doing something right.”

How right he is. This guy doesn’t take any medications, only dozens of vitamins and minerals a day, he said. He starts his day with an hour-and-a-half workout: lifting weights for an hour and swimming for half an hour. He also has a handful of promotions, including for his world-famous Power Juicer, Target and Dakim, whose mission is to use cognitive stimulation to improve the quality of life for active seniors. Oh, yeah, and he also just came out with a book, “Fiscal Fitness.” It’s about the importance of physical and financial well-being.

Perhaps more impressive than any of his physical achievements is his attitude. I certainly wasn’t expecting an infectiously upbeat, slightly sassy nonagenarian — he called me a sex goddess — for the 30-minute phone interview.

I offered to him that it’s easy to get down as we age, and lose some of that verve for life.

“They don’t have the vitality because they’re lazy!” he shouts. “They get it in their brain that they’re old. “If you think you’re an old worn-out poop that’s what you’re going to be. Don’t think of age!”

I don’t know about you, but I’m a believer.

For more on LaLanne, go to his Web site: www.jacklalanne.com.

Some LaLanne-isms:

“Anything in life is possible if you make it happen.”

“Your waistline is your lifeline.”

“If man makes it, don’t eat it.”

“If it tastes good, spit out.”

“Ten seconds on the lips and a lifetime on the hips.”

“Exercise is King; nutrition is Queen. Put them together and you’ve got a kingdom.”

Time does stand still sometimes, doesn’t it?

Take the race for the Democratic presidential candidate. It seemingly had been moving at the pace of molasses for more than a month. Like an instant replay in boxing, Barack Obama or Hillary Clinton had been slugging it out in slow motion.

Which is why last night had an almost surreal quality. Could it actually be true? Could Obama really have clinched the nomination? No. You almost have to pinch yourself that this tug-of-war could actually be over.

Long-term care providers likely are chuckling at this tortuous game of wait-and-see. After all, waiting seems to be a regular part of life in the industry.

But thankfully, the clock finally has started ticking in this arena as well. For example, the time seems to be nearing at last when the issue of physician payment cuts will be put to eternal rest – or at least for an annual slumber.

Legislators are moving to stop the 10.6% cut, which is scheduled to occur on July 1. What has bothered nursing home providers is the possibility that lawmakers might dig into the skilled nursing facility market-basket update to pay to restore the physician payments. So far, that has not happened. You can’t stop fretting yet, but at least you know a resolution likely is coming.

Providers have been holding their breath on other pending developments that are likely to figure themselves out in some fashion. The Medicare therapy caps extension process, for one, is expiring at the end of the month. Action, let’s hope, is forthcoming.

Deadlines are not always easy to make, but they serve a purpose. They force action. Whether it works in one’s favor, of course, is the big question. I’m for moving it along.

In the possible case of Clinton, it’s not easy to withdraw from the presidential race, but at some point it has to be done.

Here’s yet another story from the annals of preternaturally active older Americans: Bob Gralley, an 82-year-old resident of Oak Crest retirement community in Parkville, MD, recently completed the running portion of the Columbia Triathlon, which took place between Ellicott City and Columbia.

Gralley was a part of an Erickson Retirement Communities relay team that consisted of Executive Director Craig Erickson and Business Process Improvement Director Jen Tillman. Gralley set a record as the oldest person in the annual event.

“I did better than I thought I would do because it was a really hilly course,” said Gralley, who spoke to me on May 19, just a day after running the 10K (6.2 miles).

He ran the race in one hour and 10 minutes – not a personal best, he noted.

Maybe not for him, but Gralley’s time sure is impressive. In fact, his participation is also quite admirable. Not only is he rare to run the triathlon at his age, but he is exceptional for running one at all. It’s people like Gralley who make the rest us feel as sluggish as fries left sitting in day-old gravy.

Gralley is in good health for his age, he admits.

“I’ve been very fortunate in life,” he said. “I have had no problems that would halt me from exercising. I expect to continue as long as I can.”

He doesn’t show signs of slowing up. He runs the Baltimore Marathon each October with his son. While he ran the race fastest in his 50s, today he completes it in about five hours and 10 minutes. (Not too shabby, if you ask me.)

In case you were wondering about his exercise routine, he runs at about 9 or 10 a.m. at the Erickson community from Monday through Friday and bikes on Saturday. He runs about 20 miles every week.

Outside of running, Gralley leads a full life. He plays bridge with his wife. He also moderates a computer group and is involved in church activities. There are more than 100 clubs on the campus, he said.

“If you can’t find something to do it’s your fault,” said the father of three and grandfather of three.

His advice for staying in shape?

“I think you have to enjoy exercise to start with,” he said. “That’s the good part of it. You also have to realize the importance of it, especially as you get older. It keeps you in healthier condition and mentally healthier. It makes you feel better about yourself.”

Something for the rest of us to remember tonight as we sit in our La-Z-Boys reaching for the remote.

Things are heating up on the campaign trail, and I guess we can be grateful that healthcare is emerging as a new source of political offensives.

On Saturday, Democratic candidate Sen. Barack Obama (IL) criticized the healthcare proposal of presumptive Republican nominee Sen. John McCain (AZ). He connected McCain’s with failed Bush administration policies and said McCain’s proposal leaves U.S. residents to struggle on their own in the free market.

Meanwhile, McCain responded that Obama and Democratic candidate Sen. Hillary Clinton (NY) would add government bureaucracy to the healthcare system.

To briefly recap their healthcare plans, McCain is calling for a more market-oriented healthcare system, shifting the emphasis from insurance provided by employers to insurance bought by individuals. Obama and Clinton are calling for a more universal healthcare system. Obama wants to make private and public health insurance more readily available. One difference between their plans is Clinton wants to include an individual mandate requiring all Americans to buy health insurance, while Obama wants to create one only for children.

While other political motives likely are in play, it is a good sign that the candidates are beginning to argue about healthcare – a major topic of concern for Americans.

Unfortunately, they are still leaving long-term care out of the discussion. If the candidates are serious about system reform, they should examine what their opponents are proposing about long-term care coverage and payments.

Saturday marks the conclusion of National Nursing Home Week – and providers might be breathing a sigh of relief that it is almost over.

A week that is supposed to be celebratory was marred this year by a couple of dismal government findings.

First, speaking before a House committee on Thursday, Lewis Morris, chief counsel to the Department of Health and Human Services inspector general, said that one in five nursing homes delivers care that is directly harmful to residents.

This came on the same day that a Government Accountability Office report revealed that state surveyors missed at least one serious deficiency in 15% of inspections checked by federal officials between 2002 and 2007. That increased to 25% of the surveys in nine states.

These are critical findings that should not be taken lightly.

Now you have to pardon by insensitivity. Yes, improving care is of the utmost importance, but couldn’t the agencies have picked a different week to drop these quality missiles? You have to wonder sometimes if these occurrences are more than coincidental.

The American Health Care Association established the event in 1967. How ironic is it that the Committee on Energy and Commerce’s Subcommittee on Oversight and Investigations picked the week designed “to celebrate quality,” “strengthen relationships with family members,” “recognize staff members who demonstrate excellent caregiving,” and other worthy objectives, to shed light on the opposite?

As important as they are, the despairing part of government hearings and reports like these is that they discourage those special people and homes that work every day to do some of the toughest work there is.

And they shouldn’t. Not during National Nursing Home Week. So, listen up, all you worthy caregivers: Don’t let the government’s research rain on your parade.

**Readers, in the spirit of the week, do you have any heartwarming short stories about the nursing home or long-term care facility in which you work? If so, please share.

Last Friday, I wrote about a new quality committee formed by HCR ManorCare. I immediately received some negative feedback about the company’s move.

The Service Employees International Union was quick to pounce on my favorable stance. ManorCare shouldn’t need a committee to improve quality, an SEIU spokeswoman told me over the phone.

“You’re a nursing home company,” Julie Eisenhardt, the SEIU spokeswoman told me. “Quality care should be what you’re in the business of providing.”

She also sent me stories from the SEIU’s Web site, http://carlylefixmanorcarenow.org/, which offers its take on the new panel: “Carlyle-ManorCare’s decision to refer the issue of quality to a committee falls far short of the real and immediate action needed to improve quality of care for its residents,” it said.

The SEIU also noted that the committee is not as “independent” as the company has touted, pointing out that committee member Gail Wilensky served on the ManorCare board as recently as last year and collected a more than $1 million windfall from the The Carlyle Group buyout. She also served as vice-chair of the Maryland Health Care Commission — a state regulatory body that issued approval for the sale, according to the SEIU.

Of course, not everyone was so quick to bash the new panel. One blog reader spoke up for the committee and its members. (See more comments below the May 9 entry.)

So the question remains: Is the committee merely a PR stunt, or a legitimate way to address quality concerns? I believe that this point remains to be seen.

I might be swayed to thinking that the committee is just a pr move if it weren’t for the high-caliber of talent selected to serve on it.

- Vincent Mor, a well-known university researcher, just a couple years ago completed a comprehensive report for the National Commission for Quality Long-Term Care about challenges facing the long-term care field.

- Robyn Stone is the architect behind Better Jobs Better Care, which is dedicated to improving the hiring, retention and recognition of frontline staff. She also, by the way, works for the American Association of Homes and Services for the Aging, an association that represents the nonprofit sector. I doubt she would want to jeopardize her credibility with AAHSA or her reputation in the field by acting as a quality stooge for a chain that is already suffering from a public image problem.

- As for Wilensky, I would find it hard to believe that she, too, is not concerned about care improvements. Based on her interests in ManorCare, however, the company would have been wise to choose one of dozens of other highly qualified experts to avoid allegations of conflict of interest.

While I don’t believe that the committee is pure grandstanding, I agree with the SEIU that the panel is not a replacement for hiring trained staff at livable wages and benefits. Appointing the committee is one thing; listening to the expert panelists and acting on their suggestions is another.

If the company can use the committee to truly better itself – developing improved hiring practices, for example, then the company is acting admirably. If not, then it is just proving the naysayers’ right.