AMERICAN HEALTH CARE ASSOCIATION (AHCA).

Today's Battles, Tomorrow's Hopes

This year the American Health Care Association (AHCA) celebrates 50 years of service to the people and companies who make up the long-term care community--and to the residents and families they serve. What began, literally, as neighbor-helping-neighbor in small residential settings has evolved into a highly professional field that offers an array of services to Americans of all ages:

* Nursing facilities that provide compassionate, quality care to 1.6 million individuals across America.

* Subacute care centers that provide highly skilled care to patients who ten short years ago would have been cared for in hospitals at much higher cost.

* Assisted living facilities that offer assistance to post-retirement seniors who need daily assistance, and perhaps healthcare supervision, but don't require around-the-clock medical care.

As long-term care providers have evolved into a new, increasingly important part of the healthcare system, so have AHCA and its state affiliates played an important role in the evolution of health policy in Washington and in state capitals. From the inception of Medicare and Medicaid, to the enactment of the Boren amendment and the implementation of the nursing home reforms of the 1987 Omnibus Budget Reconciliation Act (OBRA), AHCA and its member providers have been active, influencing policy and shaping change. These public policy changes--along with many others--contributed to shaping the long-term care field as we know it today.

But two parts of current public policy, more than any others, threaten providers' ability to continue delivering quality care to elderly and disabled Americans. First, as a result of the 1997 Balanced Budget Act, skilled nursing providers have been faced with deep Medicare cuts, deeper than Congress ever envisioned, and these cuts are testing the viability of independent, multifacility, nonprofit and for-profit providers. Already, two national corporations have filed for Chapter 11 bankruptcy protection, and several smaller regional providers and independents have followed suit. Financial and other pressures are forcing many providers to make decisions about whether to participate in the Medicare program--and whether to remain in long-term care.

Compounding the funding shortfall is a government inspection system that's out of control. Government is putting a stranglehold on providers, limiting their creativity, demoralizing staff and pushing conscientious providers and staff out of long-term care.

In the face of these challenges, AHCA has identified three priorities-- opportunities to eliminate the clear and present danger that current policies create for our nation's sickest and oldest Americans, as well as for the men and women who provide their care:

* To restore Medicare funding that was cut as part of the 1997 Balanced Budget Act and to fix problems created by the new Prospective Payment System.

* To let policymakers and the public know that the current survey and enforcement system is broken, fails to measure quality and is unreliable and inconsistent.

* To maintain the drumbeat of long-term care financing reform by being sure the topic is a vibrant part of the presidential election process.

AHCA's goals regarding Medicare are to see that critical adjustments to the Prospective Payment System are made to ensure that Medicare beneficiaries have access to the skilled nursing care they need. Also, AHCA is seeking to eliminate or significantly alter the $1,500 per year caps on therapy provided in the skilled nursing setting--a policy that has had a detrimental effect on seniors throughout the nation.

As of this writing, two bills have been introduced that deal with AHCA's concerns. The first, a bipartisan bill (S. 1500) introduced by Senators Hatch (R-Utah), Domenici (R-NM), Daschle (D-SD) and Kerrey (D-Neb.),provides payment add-ons in 15 RUG categories. The bill also restores 1% to the annual market-basket update that was cut as part of the 1997 budget deal. In all, this bill would restore more than $9 billion to the SNF Medicare system over 10 years. If enacted, this legislation will help ensure that Medicare patients find ready access to quality long-term care services.

The second bill (5.472, H.R.1837) deals with arbitrary Medicare caps on the amount of rehabilitation therapy a person can receive in a year. Caps penalize patients who have the most serious medical conditions and the greatest rehabilitation needs, and often those who have opportunities to recover and live healthy and productive lives. That is why AHCA supports the Medicare Rehabilitation Improvement Act. This proposal creates exceptions to the limits and goes a long way toward addressing the needs of Medicare beneficiaries.

Another of AHCA's priorities: to change the current survey and enforcement system, which has become focused on punishment rather than improvement, on antagonism rather than collaboration. Clearly, long-term care providers are working under a flawed inspection system--to the detriment of residents, their families and caregivers. At the heart of the problem is the federal government's attitude toward inspections. But beyond attitude, the current system fails to adequately distinguish major problems from minor ones, or isolated breakdowns from system problems. And most importantly, the current system does not measure quality--or stimulate quality improvement. The system needs to be refocused on clinical outcomes and on the customer's level of satisfaction with the healthcare services being delivered.

AHCA's vision of a revised system is one that is designed to measure quality according to clinical outcomes and residents' quality of life. Essential to such a system is a collaborative relationship between providers and regulators, one in which both regulators and providers are focused on ensuring the highest quality of resident care and services.

Creating awareness about the need to reform the long-term care financing system remains one of AHCA's long-term priorities. AHCA has been proactive in calling on policymakers, especially presidential hopefuls, to reform this system. We've also led the charge to encourage consumers to take control of their own futures by planning for retirement and their longterm care needs.

In our efforts to reform the longterm care financing system, AHCA continues to support the work of Citizens for Long Term Care, a coalition led by former Minnesota Sen. David Durenberger and which AHCA helped establish. Citizens for LongTerm Care is a unique coalition of groups that coalesced around a problem, rather than a solution. The organization, which is made up of representatives from consumer advocacy organizations, provider groups and labor unions, is spending time and money alerting the nation to the fact that our society faces a crisis in how we finance long-term care. In a nation as affluent as ours, we should not force our parents and grandparents into poverty just because they grow old and need care. Citizens is built on the premise that as baby boomers age, they will swamp the system with their long-term care needs. So the group's goal is to educate the public about the coming crises and put pressure on candidates in the 2000 election to address the long-term care financing issue. Early indica tions are that presidential candidates are finding that this issue resonates with American voters, and that fact will help drive long-term care to the forefront of national issues.

During the past 50 years AHCA has led the way on many issues. AHCA will continue to be a leader in longterm care into the new millennium. As we focus on solving the problems created by implementation of the balanced budget deal of 1997, which created some of the most challenging times in our history, we also look forward to the new millennium and its promise of an even busier agenda. In 2050, when our successors look back on the past 50 years, I am confident that they will see:

* A new private-public financing system--one that provides the resources necessary to ensure quality long-term care for America's seniors and disabled;

* A healthy long-term care community that offers a broad array of quality services; and

* A quality measurement system based on patient outcomes and customer satisfaction rather than on bureaucratic processes.

The challenges ahead will not be insignificant. But I believe that the longterm care provider community will meet the needs and expectations of the new millennium with commitment, compassion and dedication to those it serves.

Gerald Baker is chairman of the American Health Care Association, Washington, DC.