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Nursing home idea a concern to critics. State would reward improvements
Ventura County Star
Watchdogs worry that dangling financial carrots in front of California nursing homes as an incentive to improve staffing and care could pad profits without helping seniors in the facilities.
The state is working out the framework of a plan that ties about $40 million in Medi-Cal rate increases next year to five care standards that include the ratio of nurses to patients, minimizing physical restraints and preventing bedsores. Beginning next summer, nursing homes that score the best in a formula based on the standards will receive more money.
Officials of the state Department of Public Health and the Department of Health Care Services say the pay-for-performance plan should drive nursing homes to improve care. Nursing home representatives say they're waiting to see exactly how performance will be measured and worry the money will help facilities that already exceed standards without helping beleaguered homes they call low performers. But they applaud the concept of linking bonuses to quality.
"I think what it does is it sets a bar for nursing homes to focus on," said Jocelyn Montgomery, director of clinical affairs at the California Association of Health Care Facilities. "They can say, 'I understand where I need to focus my attention.'"
Some senior advocates say the proposed standards don't push the bar nearly high enough. They argue the formula doesn't penalize homes that use powerful drugs to restrain patients and doesn't block bonuses from facilities that have been cited or fined for mistreating seniors or committing other violations.
"You could find nursing homes that have been responsible for abuse, neglect or the death of residents who would qualify for a bonus payment," said Deborah Doctor of Disability Rights California. "They would be able to advertise themselves as award-winning."
Also targeted is a state proposal allowing nursing homes that don't meet standards but have shown dramatic improvement to qualify for some bonuses.
"It will send another message to nursing home operators that they can get rewarded no matter how poor their care," said Mike Connors of the California Advocates for Nursing Home Reform. He argued the current plan doesn't compel nursing homes to invest bonus money directly into patient care.
"We don't think the plan as currently written will help nursing home residents," he said. "It will continue to enrich nursing home operators."
But state officials are not sure they can or should tell nursing homes how to use Medi-Cal money that is used to run their business, said Vanessa Baird, a deputy director with the California Department of Health Care Services.
"We feel we would be on some real shaky legal ground there," she said Wednesday at a meeting designed to solicit input from consumer advocates, nursing homes and other stakeholders.
State officials emphasize the proposed standards are a work in progress with a deadline set for the end of November. They acknowledged the importance of issues like over-reliance of chemical restraints and factoring a facility's track record of violations into its eligibility for bonuses.
"We hear these comments and we'd like to be able to address them," Baird said. "We haven't figured it all out yet."
The standards currently proposed also reward homes that provide immunizations and earn high marks for patient and family satisfaction. The concept of a bonus system emanates from a health budget bill signed into law earlier this year.
Perhaps the hottest debate in creating the system is which nursing homes qualify for bonuses. Baird said the state is proposing homes be scored based on whether they exceed state averages in the different categories. Scores would be totaled, and only homes with scores in the top 20th percentile would get money.
A separate payment category would be established for low-performing homes that show the most improvement.
And while some senior advocates said bonuses could reward mediocrity, others at the Wednesday stakeholders meeting contend the payment system may not deliver enough money to homes that struggle to meet standards and need the most help.
"If our goal is to change behavior in the level of quality of care that's rendered, are we investing enough money to accomplish anything?" said Gary Passmore, director of the Congress of California Seniors. "I worry that we could end up investing additional dollars into a cluster of extremely good nursing homes that are already performing well above average."
The state association of health facilities, which represents nursing homes, is pushing for changes so facilities that struggle with staffing but excel in other areas still qualify for bonuses. Montgomery offered assurances bonuses will be spent on care, contending a 2004 state law that gave many nursing homes increased Medi-Cal funding brought more staffing and other improvements.
"Things have gotten better, and they will continue to get better," she said. "The nursing homes today are not the nursing homes of 10 or 15 years ago. Things are moving in the right direction."
But watchdogs point to a journalistic investigation by California Watch that shows more than 100 nursing homes across the state actually reduced staffs despite funding boosts. Connors contends the bonus money could be better spent on other senior care programs that have been cut because of California's budget crisis.
"If money grew on trees and California wasn't broke, we would be a lot more open to a system that was tied to performance," Connors said. "But we would want a lot better system than what is proposed here."
'Change the culture'
Sylvia Taylor Stein, executive director of the Long Term Care Services of Ventura County ombudsman program, wants standards that block bonuses from facilities that use any chemical restraints. She worries that, if bonuses are spread too liberally in a scenario she sarcastically called "No Nursing Home Left Behind," the money won't end up improving care.
Stein said she doesn't oppose a bonus system that gives nursing homes more money because of excellent care. But it has to be shaped in a way that drives change and shows homes the only way they'll get more money is by providing excellent care.
"Nursing homes are institutional settings," she said. "There's a culture that comes with that setting. We need to change the culture."