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"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 issues its long-dreaded ergonomic ruling, it won't be because Paul Willging didn't try to stop it. As the long-term care 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 both giving and taking away with respect to long-term care, and with a Clinton Administration that is against both block grants and the Boren Amendment. A long-time Washington insider - as Deputy Director of HCFA - and health care topsider - with Blue Cross/Blue Shield of Greater New York - Willging "knows the ropes" of health care legislation, by all accounts. His well-articulated views - whether you love 'em or hate 'em - crystallize 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 and resource requirements 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 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 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 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 on this was the recent Research Triangle Park 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 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 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?

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 system - rather than on per diem 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. Many nursing homes are not happy about this. Your thoughts?

Willging: Of course, this would become a moot point 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.

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 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 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 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 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, 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" approach.

If we can achieve all that, then I guess I can retire.
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Author:Peck, Richard L.
Publication:Nursing Homes
Article Type:Interview
Date:May 1, 1996
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