SUSAN M. PETTEY has directed health policy and advocacy programs for long-term care physicians, administrators, and other professionals, including AMDA and the American Association of Homes and Services for the Aging. Her experience also includes work with the Health Care Financing Administration (now the Centers for Medicare & Medicaid Services) and the National Association for Home Care. She currently is a health policy consultant.
Efforts to resuscitate health care reform continued as Caring for the Ages went to press. Both pending House and Senate versions of reform contained numerous long-term care–related provisions that could become law: establishing a national, voluntary program for purchasing long-term care services (the CLASS Act); improving the Medicare Part D drug program; plans for bundling post-acute health care reimbursements; freezing or reducing nursing home and home-health inflation updates; and promoting alternatives to the current medical liability system. But crucial details remained to be resolved regarding those and many other provisions.
Meanwhile, Medicare physician payment was on the negotiation table. As a result of the 2-month extension that President Barack Obama signed last December, Congress had until March 1 to act to avert a 21% reduction in Medicare physician payments.
And nursing home survey and enforcement grabbed some of the spotlight, as the Government Accountability Office (GAO) issued two studies dealing with long-term care. Following up on its May 2008 report on significant understatement of nursing home deficiencies, the GAO identified numerous factors that contribute to the problem.
In the study leading to the new report, state survey directors and surveyors reported that weaknesses in the traditional survey methodology, such as too many survey tasks, contributed to understatement. The state survey officials said that their staffing issues also contributed to understatement of deficiencies. Nearly 75% of directors reported that they always or frequently experienced an employee shortage. Nearly two-thirds indicated that surveyor inexperience also led to understatement. Inadequate training, particularly regarding the severity and scope of deficiencies and how to document them, was also faulted.
The GAO study found no consensus about how the new Quality Indicator Survey (QIS) methodology would affect understatement. The report noted that surveyors and directors in a few states said that state agency practices or external pressure from stakeholders, such as the nursing home industry, may have led to understatement in some cases.
The GAO recommended that the Centers for Medicare & Medicaid Services:
▸ Clarify its existing guidance to reduce confusion and simplify application in the field, particularly on the definition of actual harm.
▸ Consider establishing a pool of national surveyors to augment state survey teams.
▸ Evaluate current training programs and divisions of responsibility between federal and state levels to determine how to improve initial surveyor training and continuing education.
▸ Expect states to include programs in which supervisors review surveyors' work as part of quality-assurance processes. The programs should include routine reviews of deficiencies that could cause more than minimal harm to residents, and surveyors should get feedback when their citations are deemed incorrect.
▸ Reiterate its position that official or unofficial practices of not citing deficiencies are inappropriate.
▸ Monitor trends in states' citations.
▸ Direct state survey agencies to communicate with their CMS regional offices when they experience significant pressure from legislators or the nursing home industry that may affect the survey process.
▸ Address concerns related to the QIS methodology, such as ensuring that it accurately identifies potential quality problems.
Sending in the Troops
In a second study, the GAO reviewed the states' infrequent use of their current authority to install temporary management in poorly performing nursing homes. Replacing a nursing home's managers is allowed as an alternative to termination of participation in Medicare and Medicaid when a nursing home's deficiencies place residents in immediate jeopardy.
Federal regulations require that any nursing home cited for a deficiency causing immediate or widespread risk to residents remove that condition within 23 calendar days of the survey or complaint investigation. If that requirement is not met, the CMS may install management for a short term or terminate the home from participation.
Based on responses from officials in the 10 states and 7 CMS regional offices that have used the temporary management sanction since 2003, the GAO judged the action successful in homes where there was some combination of immediate jeopardy, a history of noncompliance with CMS quality requirements, and the failure of other sanctions to bring about compliance. However, some homes continued to have compliance problems even after the conclusion of temporary management.
The broader survey of state survey agencies and CMS regional offices identified several obstacles to using the temporary management sanction, including time constraints, a lack of qualified temporary managers, and inadequate funding. Many characterized the 23 days as a short time during which to hire temporary management and remove immediate jeopardy before a home's termination from Medicare and Medicaid.
Officials from roughly half the states said they did not maintain lists of potential temporary managers who could be called upon quickly. The GAO recommended that the CMS work with states to create and maintain regional or national versions of such lists. The report also recommended that the CMS identify best practices regarding use of temporary management, including when and how to use the sanction, the essential qualifications for temporary managers, and alternative funding sources for hiring temporary managers. The CMS should also develop guidance for states to enhance their oversight, such as how to reactivate temporary management if a home does not maintain compliance for 2 years following a sanction, according to the GAO.
Tough Times
The U.S. recession apparently succeeded where other interventions failed in slowing the growth of health care spending. Growth in 2008 slowed to 4.4%, its lowest rate in 48 years, according to the CMS's actuary. Notwithstanding the slowdown, health care grew from 15.9% of the U.S. gross domestic product in 2007 to 16.2% in 2008, for total health care expenses in the latter year of $2.3 trillion, or $7,681 for every person in the country.
Spending for physician and clinical services grew 5% to $496.2 billion in 2008—a deceleration from the 5.8% growth in 2007 and the slowest rate of growth since 1996. Nursing home spending grew by 4.6%, down from the 5.7% growth rate of 2007. Nursing home spending totaled $138.4 billion in 2008. Spending growth for home health care also decelerated, from 11.8% in 2007 to 9.0% in 2008, with expenditures of $64.7 billion in the latter year. Medicare Part D drug spending increased 10.0% to $51.5 billion.
In other news of interest to long-term care professionals:
▸ An additional 1 million seniors are now eligible for financial assistance for Medicare Part D. Effective Jan. 1, eligibility requirements changed to exclude as assets the values of life insurance policies and income from friends and relatives in calculations of eligibility for the program.
▸ The Health and Human Services Office of Inspector General reported that most Medicare Part D midyear formulary changes meet federal requirements. About 64% of changes made in 2008 were positive, such as adding new drugs, reducing cost sharing, or removing utilizations controls. Among negative changes, the majority (62%) involved generic substitutions.
The CMS requires prior approval and written notice to beneficiaries taking the drugs before plans can make midyear changes. Negative changes require CMS approval and written notice to beneficiaries taking affected drugs. According to the inspector general, almost all drug-plan sponsors met notice requirements for formulary changes. The OIG found that some drug plans failed to seek approval for midyear changes, and some plans' Web sites did not include all approved changes.
▸ The Centers for Disease Control and Prevention continued to stress the need for vaccination against the H1N1 virus. Although infection has apparently reached a plateau, health officials remained concerned about a possible resurgence in H1N1 infections and an upswing in seasonal influenza. The H1N1 virus still is circulating in the United States, and the CDC is seeking to prevent a third wave of illness. H1N1 vaccine is now plentiful.
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