Sunday, September 23, 2018
Opinion

Column: A bad Medicaid plan for nursing homes

Since the early 1980s, when the state Agency for Health Care Administration conducted its last major overhaul of the Medicaid payment system for nursing homes, the quality of care in Florida nursing homes has vastly improved.

Although there are still exceptions, Florida is no longer home to the flood of nursing home horror stories that Sunshine State residents heard so frequently, and from so many homes, in the early '80s.

Improved regulatory oversight at AHCA and a payment system that rewarded nursing homes for providing high-quality care, among other factors, combined to slowly move Florida into the top tier of states in terms of nursing home quality.

In 2014, the organization Families for Better Care gave Florida nursing homes an A, one of only 10 states to receive that grade. It rated Florida fifth in the nation in terms of care quality. In its 2015 rankings of the nation's best nursing homes, U.S. News & World Report listed Florida behind only California and Ohio for the number of 5-star nursing homes in the state.

This may all be about to change.

Earlier this month, AHCA submitted a plan to the governor and the Legislature for a new approach to nursing home Medicaid payments. The plan is intended to establish an equitable payment system that includes incentives for high-quality care, simplifies the payment process, controls costs and makes legislators' budgeting for Medicaid spending on nursing homes more predictable.

What the plan will actually do is penalize the nursing homes that for the last three decades have invested in delivering the highest quality of care possible, while rewarding homes that have remained at the bottom of the quality barrel.

Under AHCA's proposal, 143 nursing homes that are rated as 4- or 5-star homes would lose significant funding. Meanwhile, 86 nursing homes that received a 1- or 2-star rating would receive additional funding. In fact, a single nursing home chain would reap $16.5 million of that unearned windfall.

Clearly, this is neither equitable nor fair. Moreover, the proposal does nothing to control Medicaid spending on long-term care, or even to make budgeting meaningfully more predictable. The Legislature decides when to fund a rate increase for nursing homes, something it has not done since 2011, and the current payment system includes caps and limits on payments.

Quality care costs money, and those costs are largely driven by staffing levels — the number of nurses and nursing assistants who are available at any given time to care for a frail senior in a nursing home. The best way to ensure that nursing home residents receive quick, consistent, quality care is to ensure a sufficient number of skilled, caring, long-tenured staff to provide that care.

Under the AHCA proposal, however, nursing homes with the highest staffing levels would lose funding, while those with the lowest staffing would gain dollars.

Nursing home care is not improved, or even sustained, by stripping funding from those that have invested in delivering high quality and shifting it to those that, for whatever reason, have not chosen to make that investment. Despite claims in earlier news reports, the plan does not require that the low performers spend any of their new money on care, nor is there any mechanism in the plan to ensure that quality improves.

AHCA's proposal is not likely to achieve any of the agency's stated goals.

It is likely, however, to reverse 30 years of progress in improving quality in the homes that care for Florida's most vulnerable seniors, and the Legislature simply must reject it.

Steve Bahmer is president and CEO of LeadingAge Florida, a nonprofit statewide association representing the full continuum of care for seniors with members ranging from nursing homes to assisted living facilities to continuing care retirement communities.

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