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Nursing Home Providers Quarrel Over Quality Payments

Agency for Health Care Administration

A bruising battle over how to parcel out billions in Medicaid payments for nursing homes is showing little signs of ending anytime soon.
The latest skirmish happened this week at a meeting where both sides of the tug-of-war were supposed to be trying to draw up a detailed blueprint for a revamp of how nursing homes get paid under the state-federal health care program.

The meeting devolved into a tense exchange when Scott Hopes, a health care consultant, snapped at a fellow member of the workgroup for not answering what he said was a “simple, yes or no question.”

Keith Myers, president and CEO of West Palm Beach-based MorseLife Health System, was interrupted by Hopes three times as he tried to respond.

It's not surprising that those involved in the nursing home industry are closely watching the workgroup, since long-term care remains one of the largest expenses in the Florida's $26 billion Medicaid program.

The state set up a nursing home prospective payment workgroup earlier this year following a contentious battle during the 2017 session over a push by some nursing homes to alter how they are reimbursed.

A prospective payment system is a reimbursement system in which rates are determined in advance of payment and considered final upon payment. Currently, the state reimburses skilled nursing facilities on a cost-based rate and rates are generally retrospective in nature.

The Florida Health Care Association pushed the Legislature to approve a prospective payment system but LeadingAge Florida said the new calculation system didn't make quality a top priority.

The Legislature agreed to the changes but pushed back implementation to October 2018. Lawmakers also tasked the State Agency for Health Care Administration with creating a work group to, among other things, assist in the development and refinement of quality measures that should be included in the reimbursement calculations.

Workgroup members agreed at their inaugural September meeting to use, as a starting point, quality metrics included in a 2016 report published by state-hired consultant Navigant. The report provided a roadmap for transitioning from cost-based reimbursement to a fixed-fee system.

After a lengthy discussion last month, the panel agreed to keep some of the quality metrics included in the Navigant report but left pending until Thursday's meeting action on more than a half-dozen other recommended changes.

Some of the proposed changes include eliminating incontinence and the use of restraints as metrics in the quality payment incentive but adding weight loss for consideration.

The additional time between meetings, however, didn't help the workgroup members to reach consensus.

After 45 minutes of debate, mostly focused on whether the proposed changes would take effect in October 2018 or in 2020, the committee voted 6-5 to delete the incontinence metric, effective next year, from consideration.

But panel member Beverly Williams subsequently said she was uncomfortable with approving any changes that would take effect in October 2018.

“I'm thinking really we should kinda stay with the way it is now until such time that we've gone a year or so and we know what's going on, which ones are problematic,” she said. “I think I am changing my first vote.”

Sensing that the technical advisory panel wasn't going to be able to come to agreement, Hopes recommended that the committee approve the quality recommendations included in the 2016 Navigant report and that a subsequent panel be appointed to further analyze the quality of care metrics.

“(Is there) such strong opposition to it (the Navigant metrics) that we cannot move this meeting forward unless we change it?” Hopes asked panel members, especially Myers.

“Some of them,” said Myers. But when Myers tried to explain his position, Hopes interrupted.

“So your problems are significant enough that you are not going to be able to live with this? We have to change it?” Hopes asked Myers.

“It's not about the organization,” Myers said, again trying to elaborate.

But Hopes interrupted Myers for a second time, asking him again whether he would agree to submitting the Navigant report or if that made him uncomfortable.

When Myers went to answer the question, Hopes interrupted him a third time.

“It's a simple question: yes or no,” Hopes said, quickly adding, “I'm trying to move this meeting along.”

Myers noted that he also was trying to keep the group on task. He reminded Hopes that the panel last month agreed to delay action on nine proposed changes until Thursday, which was why the items appeared on the agenda.

Myers also said that creating another committee to examine the quality metrics between now and October 2018 just adds another layer of bureaucracy to the process.

But Hope told Myers that his “sense” was that the panel wouldn't be able to come to a consensus on the nine issues Thursday.

He reiterated his recommendation that panel members be asked whether they supported submitting the recommendations in the Navigant report.

But this time it was Myers who retorted.

“Is that an agenda item, because that's not what I'm reading,” he said.

The back and forth ended only after Interim Assistant Deputy Secretary for Medicaid Finance and Analytics Tom Wallace suggested that the panel members submit written comments to the agency.

Wallace said he wanted the technical advisory committee's report to be a reflection of the panel's sentiments and, to that end, asked that each member provide written comments on the nine proposed changes. The comments would be included in the final report, Wallace said.

“We could definitely do that,” he said. “We like to do that.”

The three-hour meeting at the Agency for Health Care Administration's Tallahassee headquarters wasn't all controversial, though.

Nursing home technical advisory panel members agreed to temporarily defer any decision on how supplemental payments for ventilators should be applied.

The panel also agreed not to apply a 2011 law that prevents rates from being adjusted for inflation when the prospective rates are being rebased.

That recommendation was made by panelist Bob Asztalos, chief lobbyist for the Florida Health Care Association, which aggressively lobbied the Legislature to pass the prospective payment system into law.

Asztalos noted that the state retooled how it paid hospitals for inpatient and outpatient care. During that transition period, hospitals were exempt from a 2011 law restricting Medicaid rates from being annually adjusted for inflation.

After the recommendation was unanimously approved, Asztalos quipped he was beginning to feel “warm and fuzzy.”

Hopes, who had been frustrated earlier in the meeting, joined in Asztalos' optimism.

“We went from a health debate to ending our agenda with consensus,” Hopes said.