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Californians in Nursing Homes Deserve Better
CANHR Note: California Healthline published the following statements from Disability Rights California and CANHR. Additional commentary by California Healthline and others is not included here but can be found at California Healthline.
Californians in Nursing Homes Deserve Better
In 2004, we asked this question about AB 1629: Since the stated purpose of the bill is to improve care for nursing home residents, what evidence exists that AB 1629 will produce that effect?
No study, data or survey supported the revamp of the nursing home reimbursement system. We predicted that it would benefit only nursing home operators. Six years later, credible research shows that care has not improved and wages have not increased much, but because of AB 1629 the state now pays one billion dollars more per year on nursing homes -- one quarter of that from the general fund -- even as the number of people in nursing homes has declined.
Our 2010 investigation of abuse in California nursing homes revealed critical issues. In a startling re-write of history, some AB 1629 proponents say that it was never intended to improve quality, despite clear language in the bill stating that intent.
State officials now acknowledge some shortcomings of AB 1629, but in a sad parallel to 2004, their 2010 response includes another unproven plan, a "pay-for-performance" system. We've asked officials of the Departments of Public Health and Health Care Services the same question we asked in 2004: What evidence exists that this will produce better care? We have received no answers.
A 2009 article in the Journal of Health Care Financing Review contended that information on the impact of pay-for-performance programs is lacking in the nursing home setting. This literature review (1980-2007) identified 13 prior examples of pay-for-performance programs in the nursing home setting: seven programs were active as of 2007, while six had been terminated. The programs were mostly short-lived, varied considerably in the choice of performance measures and pay incentives, and evaluations of the impact were rare.
In 2004, Bruce Vladeck, former Administrator of the Health Care Financing Administration (predecessor agency to CMS), described pay-for-performance as "the kind of seductive focus group-tested catch phrase that has come to dominate health care policy discourse but is largely devoid of real content."
CMS is in the midst of an experiment using pay-for-performance in Medicare payments in nursing homes in several states. Why does California have to move ahead with yet another untested, unproven nursing home payment scheme -- one in which nursing homes found liable for the abuse, neglect and deaths of residents could be eligible for bonus payments? The 100,000 Californians in nursing homes deserve better.
We Can't Afford To Waste More Money for Poor Performance
Excuse us if we are leery of Medi-Cal's latest scheme to reward nursing homes. We've been down this road before.
Back in 2004 when AB 1629 established a new Medi-Cal rate system, nursing home and Medi-Cal officials claimed the system would improve care and accountability while saving the state money. None of these promises came true. Annual Medi-Cal payments to nursing homes increased by over $1 billion and operator profits soared, but overall care did not improve and in many cases got worse. California Watch reported in April 2010 that hundreds of nursing homes cut staff, paid lower wages or staffed below minimum standards despite the increased funding.
These findings prompted Medi-Cal officials to admit that the rate system "has no tangible mechanism for financially incentivizing, rewarding or penalizing SNFs -- skilled nursing facilities -- for the overall quality of care rendered to their residents." The Schwarzenegger administration responded by calling for a "pay-for-performance" system. Notwithstanding the catchy slogan, the new system promises more of the same.
The plan allows nursing homes to receive and profit from their current payments, no matter how poor their care. It does nothing to ensure that nursing homes earn the $4 billion Medi-Cal already pays them each year. The performance measures only determine the amount of rate increases nursing homes receive.
Making matters worse, the plan ignores most key areas of nursing home performance. It doesn't take into account inspection findings, citations for abuse and neglect, federal and state enforcement actions, or criminal investigations and prosecutions. Nursing homes can qualify for bonus payments even if they discriminate against Medi-Cal beneficiaries, chemically restrain residents, and ignore their obligation to help residents return to their homes or other community settings when they are able and so desire.
Another sign of the plan's misplaced priorities: nursing home operators can pocket the bonus payments instead of using them to improve staffing and care.
These are but a few of the plan's problems. Like the current system, it won't do much, if anything, to improve the lives of people living in California's nursing homes.
On Nov. 8, 2010, CANHR and 32 other consumer organizations wrote state officials urging them to withdraw their proposal and start over. Given the budget crisis and cuts to other vital long-term care services, California cannot afford to waste more money rewarding nursing homes for poor performance. Nursing home residents deserve a better plan.