"Boren is issue # 1...": an interview with Paul R. Willging, PhD, executive vice president, American Health Care Association.
Consider the "worst case:" If Medicaid block grants are enacted, if the Boren Amendment disappears, if HCFA's Survey and Enforcement regs continue and OSHA OSHA
Occupational Safety and Health Administration, a branch of the US Department of Labor responsible for establishing and enforcing safety and health standards in the workplace. issues its long-dreaded ergonomic ruling, it won't be because Paul Willging didn't try to stop it. As the long-term care long-term care (LTC),
n the provision of medical, social, and personal care services on a recurring or continuing basis to persons with chronic physical or mental disorders. industry's principal spokesperson in Washington, by virtue of the 11,000-plus facilities his organization represents, Willging tends to leave no doubt where his membership stands on the issues. His early condemnation of the otherwise appreciatively-received National Governors Association compromise on block grants was a typical Willging performance; while others "analyzed" it, he called it the Medicaid reform proposal that would do the most damage to longterm care. Seemingly unafraid to ruffle powerful feathers, he must yet guide his members' interests through the confusing cross-currents of Washington politicking - with, for example, a Republican Congress that seems bent on Adj. 1. bent on - fixed in your purpose; "bent on going to the theater"; "dead set against intervening"; "out to win every event"
bent, dead set, out to both giving and taking away with respect to long-term care, and with a Clinton Administration Noun 1. Clinton administration - the executive under President Clinton
executive - persons who administer the law that is against both block grants and the Boren Amendment. A long-time Washington insider - as Deputy Director of HCFA HCFA
Health Care Financing Administration
n.pr See Health Care Financing Administration. - and health care topsider top·sid·er
One who is at the highest level of authority. - with Blue Cross/Blue Shield of Greater New York New York, state, United States
New York, Middle Atlantic state of the United States. It is bordered by Vermont, Massachusetts, Connecticut, and the Atlantic Ocean (E), New Jersey and Pennsylvania (S), Lakes Erie and Ontario and the Canadian province of - Willging "knows the ropes" of health care legislation, by all accounts. His well-articulated views - whether you love 'em or hate 'em - crystallize crys·tal·lize also crys·tal·ize
v. crys·tal·lized also crys·tal·ized, crys·tal·liz·ing also crys·tal·iz·ing, crys·tal·liz·es also crys·tal·iz·es
1. his industry's position in the precarious mid-1990s. Recently Nursing Homes Editor Richard L. Peck asked Willging for an overview.
Peck: What motivated your early strong stance against the Governors' Medicaid block grant compromise?
Willging: I was frustrated both with the substance of the proposal and with its less than full disclosure of the impacts it would have on the elderly. It's one thing to acknowledge that sacrifices are needed with today's budget realities, but it's another to suggest that beneficiaries will not be adversely affected when, in fact, they will be decimated. When you say that all beneficiaries who meet SSI (1) See server-side include and single-system image.
(2) (Small-Scale Integration) Less than 100 transistors on a chip. See MSI, LSI, VLSI and ULSI.
1. (electronics) SSI - small scale integration.
2. and resource requirements The components of a system that are required by software or hardware. It refers to resources that have finite limits such as memory and disk. In a PC, it may also refer to the resources required to install a new peripheral device, namely IRQs, DMA channels, I/O addresses and memory will be covered, and you fail to tell the American people that 87% of nursing home residents on Medicaid don't meet SSI requirements, you are being less than honest.
Most distressing is how both the Clinton Administration and the Republican Congress are patting themselves on the back for maintaining quality standards, while at the same time they propose dramatically reducing funding for this and eliminating states' requirements to pay for the standards. In general, I thought it was time for someone to make clear that the emperor was totally without clothing.
Peck: Regarding the Survey and Enforcement regulations, are nursing homes faring any better under them now than they were at the outset last year?
Willging: We don't see the vocal controversy we saw back then, but that doesn't detract from the fact that this system is fundamentally and irreparably broken. HCFA has failed to meet the Congressional mandate of developing a consistent and operable operable /op·er·a·ble/ (op´er-ah-b'l) subject to being operated upon with a reasonable degree of safety; appropriate for surgical removal.
adj. system across the country. Recent data indicate, for example, that there were 0% substandard facilities in Colorado and Virginia, while in Kentucky the substandard facility rate was 45%. Unless all the "bad" facilities moved from Virginia to Kentucky, this makes no sense. HCFA's generalization that the system is "working well" is a mischaracterization.
Peck: Are you similarly dissatisfied with the application of civil monetary penalties to date?
Willging: One can see the argument for CMPs and even, in rare cases, having them applied retroactively. My concern is the apparent inclination of the system to use these fines not as a last resort, as they should be, but often as a first resort. A facility could be making serious mistakes in filling out its MDS MDS,
n See temporomandibular pain-dysfunction syndrome.
MDS 1 Maternal deprivation syndrome, see there 2 Myelodysplastic syndrome, see there and be able to rectify them quite easily, with no harm done to residents, but in the interim get hit with a fine of up to $3,000 a day. HCFA may unofficially claim that this doesn't happen, that fines really are used as a last resort, but they've never been willing to announce this as a formal position. Why is that? Does it reflect a punitive attitude, rather than one of attempting to work collaboratively with facilities to achieve and maintain compliance?
Peck: You have stated that "deemed status," which would indicate OBRA compliance based on private-sponsored surveys such as JCAHO's, would be preferable to the current State survey system. But can facilities afford the expense of private surveys?
Willging: The significance goes beyond costs. HCFA's system forces nursing home staffs to monitor for a "good surveys," not for quality resident care. JCAHO JCAHO Joint Commission on Accreditation of Healthcare Organizations, see there has gone beyond HCFA in that it measures quality based on outcomes, rather than on input and process. If we could enable facilities to monitor quality on the basis of outcomes, the value of this would far outweigh any direct costs for JCAHO surveys.
Peck: You have indicated that a key factor in paying for quality monitoring and maintenance is nursing homes' recourse to the Boren Amendment. With so many of the "powers that be" opposed to it these days, how do you gauge its chances for survival?
Willging: I wouldn't even want to speculate on this for fear of limiting the energies needed to retain it. The fact of the matter is, the Boren Amendment is critical to the very fiber of what we are trying to accomplish in providing care and upgrading nursing home quality. That is why we are making this issue #1, and will continue to do so until either we prevail or it is in fact eliminated. Certainly it is duplicitous for anyone to suggest that they are working to maintain long-term care quality while they're refusing to pay for it.
An interesting - and maybe humorous - sidelight side·light
1. A light coming from the side.
2. Nautical Either of two lights, red to port, green to starboard, shown by ships at night.
3. A piece of incidental or contrasting information. on this was the recent Research Triangle Park Research Triangle Park, research, business, medical, and educational complex situated in central North Carolina. It has an area of 6,900 acres (2,795 hectares) and is 8 × 2 mi (13 × 3 km) in size. Named for the triangle formed by Duke Univ. study documenting, quite accurately, all the improvements in nursing home care under OBRA '87. The study period ended in 1993, before the new Survey and Enforcement regulations and while the Boren Amendment was in effect. The Secretary of HHS HHS Department of Health and Human Services. and the Congress have conveniently forgotten these circumstances. Under their current proposals, quality will suffer - I can guarantee it.
Peck: Do you have any allies in this rather lonely battle to save the Boren Amendment?
Willging: The hospitals have weighed in on this, though they are not as dependent upon Medicaid and are not impacted as seriously as our industry.
Peck: AHCA AHCA Agency for Health Care Administration
AHCA American Health Care Association
AHCA American Hockey Coaches Association
AHCA American Highland Cattle Association
AHCA Australian Health Care Agreement
AHCA Austin Healey Club of America has advocated a prospective payment system for Medicare reimbursement. Do you believe that facilities have a sufficient handle on their costs to function under PPS (Packets Per Second) The measurement of activity in a local area network (LAN). In LANs such as Ethernet, Token Ring and FDDI, as well as the Internet, data is broken up and transmitted in packets (frames), each with a source and destination address. ?
Willging: It's true that, having functioned under rate systems rather than pricing systems for so long, we have some work to do. When you negotiate a price, you have to know your costs, and that's true whether it's Medicare prospective payment or managed care. We have a major initiative on this, working with Price Waterhouse and the National Subacute Care Association, to develop ways to work with prospective payment based on episodes of care - similar to the hospital DRG DRG,
n the abbreviation for diagnosis-related group.
see dorsal respiratory group.
DRG Diagnosis-related group Managed care A unit of classifying Pts by diagnosis, average length of hospital stay, and system - rather than on per diem per diem adj. or n. Latin for "per day," it is short for payment of daily expenses and/or fees of an employee or an agent. payments. We've supported the latter for some years now, but no one as yet has really studied payment per episode in this field. It will take another year or two, but we'll be prepared for prospective reimbursement when it comes.
The good thing in general about prospective payment is that it will allow managers to manage, and stop the bureaucrats from nickeling and diming us to death - you know, cutting a little under capital expenditures, a little under exceptions, a little under salary equivalents and, in general, running the facilities for us.
Peck: A variation of this may confront facilities fairly soon in the form of handling the billing for durable medical equipment Durable medical equipment is a term of art used to describe certain Medicare benefits, that is, whether Medicare may pay for the item. The item is defined by Title XVIII the Social Security Act:
Willging: Of course, this would become a moot point moot point n. 1) a legal question which no court has decided, so it is still debatable or unsettled. 2) an issue only of academic interest. (See: moot) under prospective payment. As it stands, there is some logic to nursing homes doing this, since they are responsible for delivering the full package of services - or, as OBRA puts it, maintaining the highest physical, mental and psychosocial well-being of their residents. And I don't see there being much difficulty with Part A reimbursement. The problems arise with Part B, because residents have so many funding sources that are difficult to coordinate, and there may be so-called "related parties" questions adding to the complexity, as well. Even if we just do Part A, though, I would hope that the funding would be available to pay for the additional administrative costs administrative costs,
n.pl the overhead expenses incurred in the operation of a dental benefits program, excluding costs of dental services provided. .
Peck: Moving on to an entirely different, but still pressing, concern: the apparently forthcoming OSHA ergonomic ruling. How might nursing homes prepare for this?
Willging: OSHA has never established a connection between the back injuries they contend are occurring in nursing homes and the work that is done in these facilities. There is simply no literature documenting a causal relationship. OSHA is being driven in this by the unions, particularly the Service Employees International Union, which has found OSHA to be one of its favorite agencies. The fact is, we have seen a lot of work done by nursing homes, especially the multi-facility chains, in addressing back injuries and other musculoskeletal musculoskeletal /mus·cu·lo·skel·e·tal/ (-skel´e-t'l) pertaining to or comprising the skeleton and muscles.
Relating to or involving the muscles and the skeleton. problems through staff training and so forth. There is recognition that if they don't address these issues, it could show up in their workers compensation premiums. Facilities want to do what's right for the long-term care system, and not have to be mandated by some overreaching Exploiting a situation through Fraud or Unconscionable conduct. Federal agency.
Peck: Now for one of the Big Questions, long-term care financing. Do you foresee private long-term care insurance ever being a major player in this?
Willging: Most definitely, though not as rapidly as some of our Republican friends in Congress would like. It's not going to happen in six or seven years just because that is what your Federal budget process calls for. Long-term care's reliance on public funding, which is totally inappropriate in this country, took about 30 years to get there, and it may take us another 20 to 30 years to get out. The key is to stimulate interest in private funding while slowly weaning weaning,
n the period of transition from breast feeding to eating solid foods.
the act of separating the young from the dam that it has been sucking, or receiving a milk diet provided by the dam or from artificial sources. the industry off public funding.
Our analyses show that 65-70% of residents are now Medicaid-eligible, and overall 50-60% of long-term care funding is publicly supported. We believe that we can bring this down to 35-40% over an extended period of time, if we do our jobs in letting people know about the need for private financing.
I would offer a caution to those who suggest that private insurance will "never" occupy more than, say, 40% of the market at most: What biases are they coming from?
We can look at what has happened. The Health Insurance Association of America recently released data showing people spending a higher proportion of their income on private long-term care insurance than these other analyses predicted. We see CALPERS, California's health program for state employees, selling 35,000 long-term care policies in the first four or five months of availability. If you look at Medigap insurance, now owned by some 90% of Medicare beneficiaries - far more than many would have predicted - but actually covering only coinsurance A provision of an insurance policy that provides that the insurance company and the insured will apportion between them any loss covered by the policy according to a fixed percentage of the value for which the property, or the person, is insured. and deductibles at a premium of about $1,000 a year, you have to wonder what people would spend for real insurance if they knew about it. What would they do if they knew they really couldn't rely on Medicaid, that they would have to spend down their assets and not be able to pass them along to their kids? There is a vast need for public education about this.
Peck: Before we conclude, the timing of publication of this interview very nearly coincides with AHCA's National Nursing Home Week. Any comments?
Willging: This year's theme of "Joy in Caring" is very appropriate, because it focuses on residents and staff and their relationships to each other and to the community. Staff is all too frequently ignored in the debates on long-term care, and at least we can provide recognition for them for their dedication. In fact, such recognition should occur year-round. We at AHCA extend our best wishes to all staff who are bringing quality care to residents.
Peck: Finally, if you could create the "ideal" long-term care system, what would it look like?
Willging: It would certainly not be a welfare system, which is what it has become. It would be more oriented to the private market, private long-term care insurance and managed care. It would not be artificially compartmentalized com·part·men·tal·ize
tr.v. com·part·men·tal·ized, com·part·men·tal·iz·ing, com·part·men·tal·iz·es
To separate into distinct parts, categories, or compartments: "You learn . . . , so that if your service doesn't quite fit the description of a reimbursable one, you don't get paid for it. Rather, people would be eligible for financial support wherever they happened to be on the continuum of care. We would have a system that monitors quality based on residents' needs, outcomes and satisfaction, rather than on some antiquated checklist "gotcha (jargon, programming) gotcha - A misfeature of a system, especially a programming language or environment, that tends to breed bugs or mistakes because it both enticingly easy to invoke and completely unexpected and/or unreasonable in its outcome. " approach.
If we can achieve all that, then I guess I can retire.