Looking for smooth waters

In our exclusive interview, Long-Term Living Executive Editor Maureen Hrehocik talks with Barbara Gay, director of advocacy information for the American Association of Homes and Services for the Aging (AAHSA) and Cynthia Morton, senior director of congressional affairs for the American Health Care Association (AHCA), on long-term care policy and future trends.

Describe where the long-term care industry stands in trying to preserve appropriate state Medicaid funding for skilled nursing facilities.

Gay: Our primary advocacy so far on Medicaid has been to get the biggest possible increase in the federal Medicaid match included in the economic stimulus package. As of this afternoon (February 9), both the House and Senate bills contain $87 billion to help states with Medicaid over the next two years, although the details vary on the extent to which a state’s unemployment rate will figure into the formula. Our state associations will be advocating on Medicaid reimbursement strenuously.

Morton: Nursing homes are persistent in their approach to preserving appropriate state Medicaid funds. It’s a yearly battle at the various state legislatures to preserve adequate funding for those who require nursing home care. Medicaid competes with other state programs for funds, and is most often a budget driver. Then, within the Medicaid budget, long-term care services, including nursing home care, is often the largest item within the Medicaid budget. States cover more kids and moms than nursing home residents, but nursing home residents have higher care needs and are, therefore, more expensive.

What is the Medicare payment outlook this year?

Gay: We also are keeping a close eye out for any proposals to withhold the Medicare payment update that nursing homes, home healthcare providers, and hospices would receive in 2010 (the 2009 update became effective 10/1/08.) Ordinarily, we would have a presidential budget proposal for the next fiscal year by the first week in February, but the new administration and new Congress have been preoccupied with the stimulus. We understand that President Obama will submit a very brief budget document toward the end of this month and follow up with something more comprehensive maybe in April. A budget proposal would be the first place we would likely see a proposal to withhold the payment update. We also anticipate Medicare legislation before the end of the year because the physicians’ payment relief expires December 31, 2009, and that bill could be another place where a cut in the update might be proposed.

Morton: The Medicare payment outlook is a wait-and-see game right now. We are anticipating the Obama administration budget, which was not released at the customary early February date. We, too, expect a more complete budget to come in April which will not be “dead on arrival” as the last budgets have been on Capitol Hill. This budget will be closer in line with the thinking of Democratic leadership on the Hill. We are working to make sure it does not contain cuts for nursing homes including market basket (cost of living update).

What are prospects for getting federal stimulus funding for long-term care information technology?

Morton: I anticipate that prospects for federal supports for information technology for long-term care are very good. Currently, there is language in the federal stimulus bill to do just that. Keeping that language in the bill is part of my job!

Gay: We are very pleased that the House economic stimulus bill includes our proposal for new technology grants directed specifically at nursing homes to implement electronic medical records, along with another section calling for a study of aging services technology. We are urging conferees on the stimulus bill to preserve this provision in the bill’s final provisions.

What are the prospects for federal support for quality improvement? For survey and certification reform?

Morton: My belief is federal support-especially interest by Congress-on quality improvements will come through the Five-Star Program. Several members of Congress have inquired about it and I anticipate more interest as the inconsistencies become more evident. We might see consumer outcry, too. Now that Democrats have taken over, we may see a keen interest in survey and certification reform. Once the HHS secretary and CMS director are in place and their thoughts are known, then pieces can begin to come together.

Gay: Federal quality improvement efforts currently focus on CMS’s five-star rating system for nursing homes. We are concerned about the accuracy of some of the data on which the ratings are based, especially on staffing and on survey results. The system also uses a unidimensional, composite rating, which is often misleading, rather than focusing on the multidimensional, individual ratings within the respective care areas to allow consumers to reach decisions based on their particular needs. The system also uses indicators intended to trigger further investigation as quality measures, which has resulted in lower scores for facilities caring for the frailest residents. We are working with CMS to correct these flaws in the system. We also will be working with the new Congress and new administration to carry out our Survey and Certification Cabinet’s recommendations for reforms in the system, as reported in “Broken and Beyond Repair.” (An AAHSA task force’s recommendations to reform the survey and certification system issued in June 2008.)

Is there any hope of making long-term care financing part of healthcare reform?

Gay: We are working very hard to have long-term care included in general healthcare reform. A number of organizations interested in long-term care, including the Leadership Council of Aging Organizations and the Consortium of Citizens with Disabilities, have signed onto principles for long-term care financing reform that closely track the recommendations of our Long-Term Care Financing Cabinet. This effort is one of our five big ideas for the future of aging services.

Morton: Sure, there is always hope of making long-term care financing a part of healthcare reform! But hope is different than action. Congress needs crisis to act. I’m not sure if they are there yet on long-term care reform. That doesn’t mean that AHCA won’t keep pressing. We will and we will be asking to also be a part of healthcare reform. Often long-term care is left out of these discussions because we are more complex and the dollars are significant. Congress can’t avoid the discussion anymore, so we need more than hope, we need pressure on Congress. What is different now than 10 years ago when I came to D.C. is that more and more members of Congress are of an age where they are experiencing the need for long-term care in their own families-often a mother or father. They call us and ask how to choose a facility. Once it becomes personal, one is much more understanding of how this long-term care system needs to change.

What will be the most effective tack to stem the shortage of healthcare workers?

Morton: The most effective tack to stem the shortage of healthcare workers is to increase the pool of people eligible to be CNAs. CNAs conduct some of the most important care in the nursing home. We need to better recognize this.

Gay: Another of our big ideas centers on workforce issues, not only the shortage of direct care workers, but also the shortage of other healthcare professionals-physicians, nurses, social workers, pharmacists-who have geriatric training and expertise. Our immediate efforts are focused on funding for the Title VII nurse training programs and on the Retooling for An Aging America Act sponsored by Sen. Herb Kohl (D-Wisc.) We have also formed a Workforce Cabinet and will push for implementation of its recommendations.

Is there anything the rank-and-file long-term care industry members (owners, administrators, DONs, workers) can do to help keep quality care issues in the forefront of policy decision makers?

Gay: We think effective grassroots advocacy is the single most effective means long-term care providers have of keeping the issues that concern them, their residents, and their staff at the forefront of policymaking. We always encourage our members to invite legislators and other officials, whether federal, state, or local, to their facilities to see the kind and quality of services residents receive. We also ask our members to contact legislators when bills that directly concern our field are under consideration.

Morton: There is much that our profession can do to keep our issues in front of policymakers. Our profession needs to communicate regularly with policymakers through various issue campaigns and Web sites set up by AHCA and its affiliates. It doesn’t take but a couple of minutes to use one of these Web sites to compose a letter. No communication is more effective than one coming from the frontlines of care!

What is the future outlook for long-term care?

Gay: Despite the challenges we all face, we are very excited about the future of long-term supports and services. Our field continues to evolve, giving consumers an ever-greater choice of services. Leaders in our field continue to develop best practices for delivering high-quality services, and research by our Institute for the Future of Aging Services continuously turns up new possibilities. Our country’s demographics mean that these issues will gain growing importance as the baby boom generation ages into needing help with activities of daily living. Our member-led cabinets have closely examined challenges of financing, quality assurance, workforce, and technology and have recommended solutions to get us to a healthy, ethical, and affordable system of long-term supports and services.

Morton: What is the future outlook? Hmm…I take a pretty futuristic outlook in that I believe care for the baby boomers will not exist as we know it today. They may not be prepared financially, but they will demand care in a very different way. It’s important that the profession remain strong and able to care for the baby boomers.

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