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'Mr. Nice' and 'Mr. Tough'.

The years of gloom and doom between enactment of OBRA '87 and the first site visits are over, and both sides seem to be settling down to discuss how the reforms can be made to work. As presentations, however, at the recent Washington meeting of the American Association of Homes for the Aging made clear, some aspects of OBRA remain uncertain - even to the regulators at HCFA.

For Thomas Hoyer, Director of HCFA's Division of Provide; Services, it was not possible as yet to define OBRA's stated goal of achieving the "highest practicable level" of residents' mental, physical and psychosocial well-being. "I don't expect to find out (what it means) for a couple of years," Hoyer said, "but I know that it doesn't mean the "highest possible level." By using the word "practicable," Hoyer said, Congress intended to emphasize the nursing home as community devoted to quality of life, rather than as a technically-oriented facility bent on achieving rehabilitation goals at all costs.

This was not quite how the situation was seen by Anthony Tirone, Director of HCFA's Office of Survey and Certification. Rather than envisioning a long-term process leading to an idealized result, Tirone said that now that his survey teams have the final guidelines, that all states have HCFA-approved Resident Assessment Instruments, and that therefore "the tools are in place to do the surveys; we expect (nursing home) operators to meet those survey requirements." "

"Nice guy" Hoyer and "tough guy" Tirone seemed to move closer in their concepts of OBRA, however, during the question-and-answer period following their presentations. They agreed, for example, that the growing number of intermediate care and specialized care facilities could force some quality assurance standards to be modified once more. They also agreed that far fewer nursing homes today are being cited for significant numbers of deficiencies. Hoyer, for example, told the audience that only 3% of nursing homes surveyed during the last quarter of 1991 were cited for chemical restraint deficiencies, compared to 1 of 9 in the last quarter of 1989.

Long-Term Care Legislation (At Last)

After months of hints, promises and false starts, a bill offering major reform in long-term care financing has been introduced by a quartet of Democratic "heavy hitters" (Senate Majority Leader George Mitchell, Maine; Senator Jay Rockefeller, West Virginia; Representative Henry Waxman, California; and Representative Richard Gephardt, Missouri). It would provide up to six months coverage of nursing home costs for all Americans, regardless of income, with a 20% co-payment. The co-payment and care beyond six months could be covered, however, by private supplemental insurance, monitored by the Federal government and encouraged by tax and asset-shielding incentives.

Residents'spouses would be protected from impoverishment by a provision allowing married residents who live in a nursing home for more than six months to shield their home, their spouses' income, and up to $60,000 in other assets without losing eligibility.

As of this writing, neither the American Health Care Association (AHCA) nor the American Association of Homes for the Aging (AAHA) have officially endorsed the legislation. AHCA is busily drafting its own recommendations for long-term care financing and AAHA wants more time to analyze the bill. Both agree, however, that the proposal is a major step forward.

They (and others) agree, too, that its chances of passage this year are virtually nil. The White House has already promised to veto any health care financing legislation that makes a major change in the system. Even without the Bush Administration's opposition, the $45 billion price tag that some analysts have placed on the bill may be enough to discourage today's budget-conscious legislators, whatever their political leanings. At the very least, though, the bill may serve as a model for future reform measures that could pass should more comprehensive national health insurance be ruled out.
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Title Annotation:A View from Washington; Thomas Hoyer, Anthony Tirone
Author:Stoil, Michael J.
Publication:Nursing Homes
Date:May 1, 1992
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