Nursing homes will ‘fulfill the promise’ in spite of tough budget outcomes

Guest editorial, Tallahassee Democrat, May 12, 2011
By J. Emmett Reed, CAE

This week is National Nursing Home Week, which is typically filled with celebrations to honor the staff, family members and volunteers who make a difference in the lives of our state’s nearly 71,000 nursing home residents. But with the sting of the 2011 legislative session still being felt across Florida, many celebrations will ring hollow as nursing homes look to cope with the Legislature’s $187.5 million funding cut that will come their way in July.

This year’s theme is “Fulfilling the Promise.” Ironically for the past three years, nursing homes have been asking lawmakers to keep their promise and protect the funding that is critical to resident quality care. Nursing homes have done their part to assist by contributing to the state’s General Revenue through the Nursing Home Quality Assessment, where they essentially tax themselves to draw down additional federal funds. Since tougher standards on nursing home staffing were put into place in 2001, long term care providers have gladly kept their end of the promise, hiring nearly 11,000 nurses and CNAs to provide that direct quality care to residents.

In the final days of session, AARP was highly critical of changes proposed by the Legislature to nursing home care, which everyone recognizes is among the nation’s best. More recently, they’ve also criticized legislators for reducing the amount of staff required in nursing homes which are the direct result of significant funding cuts. Nobody is happy with the budget cuts made by the Legislature to long term care. We would have preferred legislators maintain the funding and staffing requirements, and in fact over 400 long term care professionals descended upon the Capitol fighting budget cuts throughout the entire 60 day session. I am dismayed that AARP was not beside us opposing these cuts and in the very end, rose up in indignation against the reduced staffing that resulted from these cuts. Medicaid providers must be compensated to pay for the level of staff necessary to provide excellent care, and it is my hope all parties work constructively toward that goal.

The reality is that nursing homes, unfortunately, will find a way to do more with less. They will continue to operate efficiently while improving the quality of care and quality of life for their residents. With 70 percent of nursing homes costs paying for the people working in the facility, reducing pay or even staff will become a reality. Because of government limitations, valuable caregivers who work in nursing homes are paid less than they deserve, despite the physical and emotional challenges of caring for residents. Facilities will also struggle to continue the programs that offer quality of life, which is just as important as health care. Most will lack the ability to invest in improvements.

In a week designated to celebrate nursing homes, we will still recognize the vital role they play in our state’s health care system. Not only as a place for the frail elderly who cannot care for themselves, but as a cost-effective setting for patients with short term rehabilitative needs. But with Florida on the verge of a boom in the elderly population, this year’s National Nursing Home Week message is not one of celebration, but rather caution to legislators, AARP and other advocates – don’t abandon Florida's seniors. Nursing homes will continue to do their part to “Fulfill the Promise” and keep that commitment to delivering quality long term care for years to come, and we thank them for all they do to provide compassionate, quality health care to our frailest elders. But the state must keep its promise as well, and we hope as revenues begin to return to normal, legislators will stand up for our state’s seniors and restore funding for quality care to ensure they are able to live out their later years with dignity.

2011 Legislative Session: Medicaid Reform and Long Term Care

In the final week leading up to the end of the 60-day session, legislators held closed negotiations before reaching an agreement on how to overhaul the state’s $22 billion Medicaid program. HBs 7107 and 7109 passed along mostly party lines, and FHCA is pleased to report that the final legislation includes most of the important long term care provisions that were developed by the Association’s Long Term Care Reform Task Force and adopted by the FHCA Board of Directors and Our Florida Promise Steering Committee. Below is an analysis of what's included in the final legislation:

• Establishes the statewide, integrated managed care program for all covered Medicaid services, including long term care services.
• AHCA shall begin implementation of the long term care managed care program by July 1, 2012 (required to provide notice of invitations to negotiate), with full implementation in all regions by October 1, 2013.
• Medicaid recipients 65 years of age or older or eligible for Medicaid by reason of a disability and determined by the CARES Program to meet the requirements for nursing facility care are eligible. 
• All Medicaid recipients who are either residing in a nursing facility or enrolled in a Medicaid waiver program on the date long term care managed care plans become available in their region are automatically eligible to participate for up to 12 months without being re-evaluated for their need of nursing facility care.
• Establishes eleven (11) regions with a minimum of two plans for each region.
• Plans must offer network contracts to all nursing homes, hospices and aging network service providers that have previously participated in home and community-based waivers in their region for the initial period between October 1, 2013 and September 30, 2014. Plans may exclude providers after this period for failure to meet quality or performance criteria.
• Nursing homes and hospices that are enrolled Medicaid providers must participate in all eligible plans selected in their region.
• Plans shall monitor quality and performance of each participating provider using measures adopted by and collected by AHCA and any additional measures mutually agreed upon by the provider and the plan. (This provision should prevent duplicative surveys.)
• Plans must pay nursing homes an amount equal to the nursing facility-specific payment rates set by AHCA; however, mutually acceptable higher rates may be negotiated for medically complex care.
• For recipients residing in a nursing facility and receiving hospice services, the plan must pay the hospice provider a per diem rate set by AHCA minus the nursing facility component and shall pay the nursing facility the applicable state rate.
• Plans must ensure that electronic nursing home and hospice claims that contain sufficient information for processing are paid within 10 business days after receipt.
• AHCA must establish nursing facility specific payment rates for each licensed nursing home based on facility costs adjusted for inflation and other factors as authorized in the General Appropriations Act. Payments to long term care managed care plans shall be reconciled to reimburse actual payments to nursing facilities.
• AHCA must establish hospice payment rates and payments to long term care managed care plans shall be reconciled to reimburse actual payments to hospices.
• AHCA shall periodically adjust payment rates to the managed care plans to account for changes in the level of care for each managed care plan and shall make an incentive adjustment to encourage the increased use of home and community-based services. (Specific percentage adjustments are detailed in the bill until such time that no more than 35% of the plan’s enrollees are placed in institutional settings.)
• By August 1, 2011, AHCA must establish the technical advisory workgroup to assist in the development of the long term care managed care program. The workgroup will address the following:
• Method of determining Medicaid eligibility.
• Method for managing Medicare coinsurance crossover claims.
• Uniform requirements for claims submissions and payments, including electronic funds transfers and claims processing.
• Process for enrollment of and payment for individuals pending determination of Medicaid eligibility.
• Continues the Comprehensive Assessment and Review for Long Term Care Services (CARES) program. Allows for the contracting of any function of the CARES program.
• Effective July 1, 2012, AHCA may not impose conditions or sanction on providers for failure to meet CON conditions related to minimum Medicaid occupancy.
• Extends the CON moratorium on nursing home beds.

To read more about how long term care fared in the 2011 legislative session, click here to read FHCA's 2011 Legislative Session Wrap-Up Report.

2011 Legislative Session: Budget Wrap Up

The budget (SB 2000) provides $2.727 billion for nursing home care which reflects a 6.5 percent cut ($187.5 million) to nursing home funding, which amounts to an average reduction of $288,932 annually per facility or $12.07 per Medicaid patient day. FHCA has developed documents estimating the impact of the 6.5 percent reduction, including facility-specific impacts by House and Senate district and summaries by county, which you can access by clicking here.

The budget does not eliminate nor modify bed hold policy and funding. Adult vision, hearing and dental services were fully funded. Also included in the budget are $26.1 million for the Assistive Care Services, $35.1 million for the Assisted Living Facility Waiver, $355.8 million for the Capitated Nursing Home Diversion Waiver and $14.3 million for the Program of All-Inclusive Care for the Elderly (PACE). Nursing home funding for case load growth was utilized to fund 1,000 additional Diversion Waiver slots, 1,250 additional Aging and Disabled Waiver slots and 275 additional PACE slots. And finally, there were no funding cuts to the Medically Needy and MEDS-AD programs.

The budget conforming bill (SB 2144) includes language that modifies staffing to lower the combined average weekly nursing and CNA staffing standard from 3.9 to 3.6 hours per patient day. The daily nursing standard of 1.0 hours per patient day remains unchanged, and the daily CNA staffing standard will be reduced from 2.7 to 2.5 hours per patient day.
 
The conforming bill also expands the Quality Assessment to the maximum federal allowance which will increase the total annual assessment from $349 million to $381 million, allowing most of the prior year rate cuts to be bought back.
 
To read more about how long term care fared in the 2011 legislative session, click here to read FHCA's 2011 Legislative Session Wrap-Up Report.

FHCA Provider Program

Hear an update on long term care as the 2011 Legislative Session draws to a close.

State budget update: nursing homes will see 6.5 percent funding cut

The House and Senate finalized the budget Tuesday. Nursing homes will see a 6.5 percent cut ($187.5 million) to Medicaid funding, which amounts to a reduction of $288,932 annually per facility or $12.07 per Medicaid patient day. The budget conforming bill is expected to include language to give providers some ability to offset these reductions with staffing flexibility to meet the needs of residents. With nearly 70 percent of nursing homes' operating costs paying for the people delivering resident quality care, facilities will have a difficult time recouping from this level of funding cut - forty percent of nursing homes statewide will begin operating with negative margins. Some facilities stand to lose as much as $1.2 million. FHCA has developed documents estimating the impact of the 6.5 percent funding cut, including facility details by House and Senate district and summaries by county, which you can access by clicking here.

With the close of the 2011 session just a few days away, FHCA is still working vigorously to advance tort reform as another means to help facilities reduce their costs. On Monday, the full House passed HB 661 by Reps. Matt Gaetz and Shawn Harrison. FHCA is still hopeful that the Senate companion, SB 1396, can be withdrawn from committee and voted on the Senate floor. Please continue with your calls and emails to Senators and ask them to support HB 661/SB 1396 with NO amendments. You can use the alert we’ve drafted to send the message by clicking here. Lawsuits do nothing to improve quality care, and every dollar not spent on litigation can be used for the health care needs of patients and residents.

Legislative Alert - Help Advance Nursing Home Tort Reform

Email your Senator and ask them to support HB 661/SB 1396 to ensure precious Medicaid funding goes toward nursing home quality care and not lawsuits.

Today, nursing home tort reform moved a step closer as the full House passed HB 661 by Reps. Matt Gaetz and Shawn Harrison. PLEASE ACT NOW! Email your Senator and ask them to support HB 661/SB 1396 with NO amendments. Simply click here to use the message FHCA has developed or craft your own. We are in the final week of the legislative session and need to increase the number of voices speaking up for long term care to urge their support of nursing home tort reform. Lawsuits do nothing to improve quality resident care. Every dollar that is not used for lawsuits goes into the quality health care of our patients and residents. Thank you for taking action today and helping with this important issue.

The final countdown - budget and bills update

Just one week remains in the 2011 legislative session, and final budget negotiations are expected to be finalized any day. If the Legislature is going to finish by Friday night, the final agreed-upon budget must be on lawmakers’ desks by Tuesday night to start the 72-hour waiting period before a vote can take place. Legislative leaders say they think they can finish “on time,” but haven’t said what time Tuesday they anticipate a final budget printing.

SB 1972, Medicaid Reform, is on the Senate Special Order calendar today; there is still no deal, but they are getting closer.

What happened last week . . .

On Wednesday, conferencing on the budget began and the House took an unfortunate position of cutting nursing home Medicaid funding by 8.5% ($245 million). Member action alerts were sent out asking for assistance with contacting key legislators in the budget decision-making process to urge them to reduce the nursing home funding cuts which threaten the financial viability of facilities and more importantly, resident quality care. Legislators must understand that cuts of this magnitude would result in facilities losing $377,831 annually, or $15.78 per patient day. Over the weekend, this issue was bumped to the Senate President and Speaker of the House.

Despite emotional testimony and debate, HB 661 by Reps. Matt Gaetz (R-4) and Shawn Harrison (R-60) passed favorably out of the House Health & Human Services Committee on Monday. On Friday, HB 661 rolled over to third reading after lawmakers debated the measure, with Democrats generally opposed to it and Republicans defending the measure. Several amendments that were offered by Rep. Mia Jones, D-Jacksonville to offer more protections to nursing home residents were rejected. The Senate companion, SB 1396, is still locked up in the Judiciary Committee, but FHCA is hopeful it will be withdrawn so the bill can move.

HB 119 (Rep. Matt Hudson, R-101), which contains important nursing home deregulation, passed in the House with a 106 yes/6 no vote. It is now in Senate messages. The Senate companion, SB 1736, is still in the Budget Committee, but the Senate President said bills in Budget can be heard on the floor.

On Wednesday, the Senate amended and approved SB 1992 by Sen. Ronda Storms (R-10) on background screening. The bill contains two amendments requested by FHCA to preclude CNAs from having to undergo duplicative background screenings for both employment and testing. In addition, the bill allows employers to hire persons prior to the screening completion if they will not be working with vulnerable adults. Finally, the bill creates an interagency work group designed to address problems of duplication and coordination among state agencies conducting background screening. SB 1992 passed its third reading on Thursday and now heads to the House, where its companion, HB 7233, awaits. We understand the House bill will be modified to reflect SB 1992 with no changes.

On Thursday, the full House passed HB 311 by Rep. Ken Roberson (R-71). This good bill eliminates municipalities' ability to impose an occupational licensure tax on certain employees, including your CNAs, working within business entities already paying the tax. The House has now sent the bill to the Senate. We are hopeful its companion, SB 582 by Sen. Nancy Detert, which has been waiting in the Senate Budget Committee, will now move.

FHCA will continue to keep you posted on the final outcome of the budget and the bills we're tracking. In the meantime, please continue contacting your legislators and ask them to reduce the nursing home funding cuts and support those bills that help preserve Medicaid funding needed to continue resident quality care. Click here to TAKE ACTION!