WV HEALTH
LONG TERM CARE
CON STANDARDS MEETING
SONIA CHAMBERS:
Why don't we go ahead and get started?
Do I need all three of these?
They look like the same.
MALE VOICE:
One of them is long term care.
One of them is assisted living.
One of them is legally unlicensed.
SONIA CHAMBERS:
Legally unlicensed? Okay. All right, why don't we go ahead and get
started? I’m Sonia Chambers. I’m
chair of West Virginia Health Care Authority.
We are holding a series of meetings to look at the issue of whether
things that are currently subject to Certificate of Need should continue to be
so. This is our fourth, I think, of
these meetings, looking at different services.
We appreciate everybody’s time and interest today in looking at long
term care. What we’ll do is we’ll go
hear who’s on the phone and go around the room here, and then Dayle has
unearthed the standards and we’ll very briefly outline those. And then we will take comments from
everybody. So, why don't we start with
who is on the phone.
PHIL WRIGHT: Phil
Wright, The Health Plan.
SONIA CHAMBERS:
Anybody else?
SUZANNE MESSENGER:
This is Suzanne Messenger [phonetic], state long term care ombudsman,
Bureau of Senior Services.
SONIA CHAMBERS:
Anybody else? Anybody else on the
phone? All right. In addition to myself, we have Marilyn White and
Sam Kapourales, who are both board members of the Health Care Authority. And then we will go around the room and start
with Jesse.
JESSE SAMPLES:
Jesse Samples [phonetic] with West Virginia Health Care Association.
RAYMONA KINNEBERG: Raymona
Kinneberg, Bill J. Crouch & Associates.
NATALIE HOLLAND:
Natalie Holland, [phonetic] senior director of development for Genesis.
ED HAMILTON:
Ed Hamilton,
DEE KRAMER:
Dee Kramer [phonetic], Office of Health Facility Licensure and
Certification Nursing Home program.
NORA MCQUAIN:
Nora McQuain [phonetic] I’m director of facility based and residential
care for BMS.
CINDY DILLINGER:
Cindy Dillinger [phonetic], West Virginia Health Care Authority.
TIM ADKINS:
Tim Adkins [phonetic], West Virginia Health Care Authority Certificate
of Need.
SHEILA KELLY:
Sheila Kelly [phonetic], Certificate
of Need Division.
DAYLE STEPP:
Dayle Stepp [phonetic], CON.
MARTHA MORRIS: Martha
Morris. I’m with the Insurance Commission, - -
office.
JESSE PLEIN:
Jesse Plein with the Insurance Commission.
STEVE WISEMAN:
Steve Wiseman [phonetic], with the Developmental Disabilities
Council.
TINA MAHER:
Tina Maher [phonetic], Olmstead Office, DHHR.
JOHN MULLINS:
John Mullins [phonetic], Health Care Association.
PAT KELLY:
KAY MYERS:
Kay Myers, Certificate of Need, Health Care Authority.
JILL MCDANIEL: Jill
McDaniel [phonetic], Hospital Association.
MARIANNE KAPINOS: Marianne
Kapinos, General Counsel, Health Care Authority.
VICKI SIMPSON:
Vicki Simpson [phonetic],
SONIA CHAMBERS:
Great. Anybody else on the phone
who did not identify themselves before?
No? Okay. I will say this. We had a little trouble finding the standards
because they haven't been updated in some time.
Dayle’s going to briefly outline.
DAYLE STEPP:
These standards were written in 1982 and the moratorium was put in place
in 1987. So these standards were never
updated because of [beep]. Going through
some of the standards, it talks about the maximum number of 30 skilled in
intermediate nursing home beds per 1,000 people, aged 65 and older, would be
the goal, with a ceiling of 33 per 1,000.
It was approved with the 1978 plan, which would allow for some growth in
the reasonable upper limit.
Some of the
criteria for this was that citizens should have to travel no longer than 60
minutes to reach a nursing home. County
and regional boundaries should be followed where feasible. And unless accessibility is serious hindered
the nursing home area should be large enough to support at least one 60-bed
facility, and where the population permits, at least one 120-bed facility.
In these
’82 standards, there was some criteria replacement of existing beds. 95% of the applicants must come within the
service area. And there was a section
that even said that applicants requesting new beds for a service area in excess
of the 30 beds may obtain an exception if certain conditions are met. And I think those were made moot by the
moratorium in ’87.
The ones
that we look at now basically have to do with what’s called objective REM8-4.5
[phonetic]. And it talks about—this was
written in ’82, and it said, during the next five years, supply nursing home
bed meets demands, the major financial transactions in the nursing home
industry will be in the sale of the facilities rather than construction of new
beds. These homes will in many cases be
purchased and the replaced. Then it
talks about since—speaking of 1981, approximately 70% of the residents in
nursing homes receive some sort of public support. Therefore the public has a financial interest
in the sale of nursing homes.
And they
talk about the seasons approving the sale is difficult because one of the
reasons is the potential conflict of interests versus the rights of the public
sector. Private entrepreneurs should
have the right to buy or sell after a reasonable financial agreement. However, by capping the number of beds,
nursing home beds and setting the rates for 70% of the residents, the public
has nearly guaranteed this private entrepreneur demand and a profit. The public should therefore be able to
extract certain benefits from the private sector.
And one of
these benefits should be the sale or change or ownership should result in
continued cost effective and efficient services for the residents and that the
public should not have to pay excessively for such a transaction. And then it goes into a discussion of if you
keep selling the nursing homes and turning them over, paying a higher price
each time, it would affect the public interest in this. They end by saying reasonable standards of
review on the sale of the nursing home must be established. These should prohibit the passing on
excessive additional costs that are not in the public interests and attempt to
ensure continued cost effective quality care.
It says the
basis for these standards should be the standards appraised value system of
reimbursement. The standard appraised
value is designed to provide reasonable reimbursement on investment and uses
model facility standards recognized construction cost allowances and physical
and functional depreciation allowance to estimate property value.
Nevertheless,
the standards we look at now on nursing home sales, the amount of the sale
price should approximate the SAV. This
is on their guideline. It should be
applied with flexibility. They have to
submit the most recent report of the survey of their facility and any plans to
correct deficiencies. That the purchaser
must agree to hold no more than 5% empty beds for private pay. And except for those 5% must agree to accept
to all Medicare or Medicaid qualified patients when beds are available. And that the nursing home, the buyer has
considered less restrictive alternatives to nursing home care, such as adult
day care, respite personal care, home delivered meals, senior centers,
community and nutrition programs and things like that. So those are the standards we generally look
at now when we get a nursing home sale.
SONIA CHAMBERS:
All right.
PHIL WRIGHT: We
keep talking about sales, are there any new ones being built?
SAM KAPOURALES:
No.
PHIL WRIGHT: No?
SAM KAPOURALES:
The moratorium states that no hospital or nursing facility can add any
licensed beds to their current license complement So basically that restricts any new nursing
beds.
SONIA CHAMBERS: Phil,
since the moratorium was enacted, there have been some addition of beds. They’ve primarily been by legislative
exception for hospitals that were converting full service acute status to
critical access. So there were a number
of those hospitals who when they converted turned a lot of those—their regular
acute care beds into long term care units.
SAM KAPOURALES:
And those were Medicare only beds.
SONIA CHAMBERS:
Yeah.
FEMALE VOICE: No, there were a few—
SAM KAPOURALES:
[interposing] No, there was a few exceptions to that legislation to
allow a couple of hospitals to have Medicare or Medicaid certified beds.
PHIL WRIGHT: Does
the Health Care Authority set the amount of what a long term care facility can
charge?
SONIA CHAMBERS:
No.
PHIL WRIGHT: No?
SONIA CHAMBERS:
No.
PHIL WRIGHT: So
that’s why you’re concerned about the selling price. Too many sales, the price increases with the cost. Is that it?
SAM KAPOURALES:
Well that could happen, except that—and I don't want to speak for
medical services, but I think they have within their calculation of the
reimbursement, the standard appraised values used for the capital cost of that
facility.
PHIL WRIGHT: So
what’s the range of prices to get into long term care?
SONIA CHAMBERS:
What do you mean the range of prices?
PHIL WRIGHT: If
I wanted to put my relative into a long term care facility, what would be the
low and the high in the state?
SONIA CHAMBERS:
Jesse, do you know the answer to that off the top of your head?
JESSE SAMPLES: I
don't know what the high or the low is, but the average is about $190 a
day.
SONIA CHAMBERS:
That’s about the average, Phil.
PHIL WRIGHT: You
know, wouldn’t it be more prudent if you’re going to have a Health Care
Authority looking at this to set the rate instead of worrying about the sale
and building of all these? I mean I keep
thinking about ten years when the Medicare population is going to grow by 30
million throughout the country. I mean
isn't that more important knowing you’re going to need a lot more of these
facilities. Instead of trying to control
the sale and the pricing that way, control it through an application through
the state.
RAYMONA KINNEBERG: Phil,
this is Raymona Kinneberg [phonetic].
And the vast majority of residents of these facilities are paid for by
either Medicare and Medicaid and they set their own rate.
PHIL WRIGHT: Right. But then there’s those non-Medicare or
Medicaid that they have appraised for also.
SONIA CHAMBERS:
Jesse, do you know what percentage of nursing home patients are not
Medicare and/or Medicaid?
PHIL WRIGHT: Thirty
percent.
JESSE SAMPLES:
No.
PHIL WRIGHT: No?
JESSE SAMPLES:
No, they’re probably 75% are Medicaid.
Probably close to 15% are Medicare.
And about 10% are private pay.
PHIL WRIGHT: But
aren’t those benefits limited to so many days.
FEMALE VOICE:
Have to be Medicare.
JESSE SAMPLES:
That’s Medicare.
MALE VOICE:
Private pay.
JESSE SAMPLES:
Yeah, Medicare is limited to 100 days of benefit.
PHIL WRIGHT: Right. So you’ve got 260—
JESSE SAMPLES:
[interposing] It still makes up 15% of the census days.
PHIL WRIGHT: Yeah,
but you still have 265 days of non-Medicare.
So what, I guess the question is what percent would be non-Medicare and
non-Medicaid.
JESSE SAMPLES:
Like we said it’s about 10% of the utilization is non-Medicare,
non-Medicaid days.
PHIL WRIGHT: Total?
JESSE SAMPLES:
Total.
SONIA CHAMBERS:
Yeah.
PHIL WRIGHT: Whoa.
TINA MAYER:
Does the $190 per day cost include patient share or is that just…
MALE VOICE:
That includes—
SONIA CHAMBERS:
[interposing] Wait just a second.
I forgot to remind everybody.
We’re having these meetings recorded and there will be a transcript, so you
have to identify yourself if you’re going to speak. So that your question or words can be
attributed to you.
TINA MAYER:
Tina Mayer.
SONIA CHAMBERS:
Tina Mayer.
TINA MAYER:
Does the $190 per day, does that include patient share?
MALE VOICE:
It includes the patient resource amount.
SONIA CHAMBERS:
So we have also provided, and we’ll put these on our website if they’re
not there already. We also have a map of
DAYLE STEPP:
No, this is the listing that GIS used to make the map.
SONIA CHAMBERS: I
see. Okay, so we have a map. We have the list of the facilities on the
map. And then—
DAYLE STEPP:
[interposing] This is the—
SONIA CHAMBERS:
[interposing] The other handout.
DAYLE STEPP:
This is from the - - website and I just found this a day or two
ago. The first one, it says long term
care all types. And this is the skilled
nursing and the intermediate care. The
second is the assisted living residence homes.
And the third is legally unlicensed, which are all part of long term
care.
SONIA CHAMBERS:
But of all of those, of those three types, what is regulated by Certificate
of Need?
DAYLE STEPP:
Just the long term care, which is the nursing home beds.
SONIA CHAMBERS:
Just nursing home beds.
DAYLE STEPP:
Right.
SONIA CHAMBERS:
Okay. So with the moratorium,
except for those legislative exceptions, there have not been an addition of
long term care beds as we define them.
There have been some replacements of those under fairly strict
conditions. And then we have allowed
very limited movement of some beds within a service area.
DAYLE STEPP:
Correct.
SONIA CHAMBERS:
So that other than that, there hasn’t been a lot of change. Some beds have been de-licensed and I would
say one reason for that would be Medicaid’s payment policies on occupancy
rates.
PHIL WRIGHT:
This is Phil Wright [phonetic].
Do we know the census and the capacity levels?
SONIA CHAMBERS:
They’re on the chart.
DAYLE STEPP: This
is Dayle again. For long term care, for
the nursing home beds, there’s 11, 202 beds.
And that includes the hospitals that might have distinct part units and
a couple of what are called life care retirement centers that have some skilled
nursing beds attached to them.
MARILYN WHITE:
This is Marilyn with the Health Care Authority. Of the total beds, is there an of what the
daily census, or do we have beds that aren’t being utilized?
DEE KRAMER:
This is Dee Kramer with OFLAC [phonetic]. Yes, we have beds that are licensed but not
in use, not available for use. For
example,
SONIA CHAMBERS:
Pine Crest is a state facility still, isn't it?
DEE KRAMER:
But it is a licensed nursing home.
SONIA CHAMBERS:
Correct.
MARILYN WHITE:
Do we have geographic areas to where this wouldn’t be true? I guess, I’m from the northern panhandle and
I’ve been under the impression that sometimes have to wait and wait to get into
a bed.
MALE VOICE:
Marilyn, this is - - we’re from
the geriatrics side, it does have a waiting list. And one of the things they’re having a hard
time with is that they have on their campus both personal care and assisted
living. And because those have grown
when those people - - . Their facility is fully occupied and they’re
having a hard time - - and they do have a waiting list. But they really have on of the highest
occupancy rates in the state. They’re
looking for a way to get a little bit of relief, just being able to add just a
few more bed to the bed complement to take these folks in. Or another alternative would be to look at
taking specialized units, like an Alzheimer’s unit and allowing that to be
separated or in another building and then open those beds up for regular long
term care. So that’s one of the things
we’ve actually—
RAYMONA KINNEBERG:
[interposing] And this is Raymona Kinneberg, I think in other areas of
the state we’ve seen occupancy such that facilities have even de-licensed
beds. And that’s within, that’s in this
calendar year that that’s happened in a couple of areas. So one of the questions is, are there enough beds? Are they in the right location? Sonia said that you’ve had limited allowing
beds to move. Maybe we need to look at
how the service areas are set, particularly because in the 1982 standards it
was done by stan [phonetic] zones and those don't exist anymore.
SONIA CHAMBERS:
This question came up, has come up on a number of occasions and a couple
of years ago a number of you in this room were involved. And we got a task force together to look at this
very issue because a number of facilities had come to us and wanted to move
beds, not just within a traditional service area, but from Point Pleasant to
Clarksburg, to really sort of out of a county or out of a county and contiguous
counties.
And we
convened a group and looked at the supply, the potential demand, five years,
ten years, fifteen years down the road.
Looked at all sorts of different projections and use rates. And I think in the end determined that there
were certainly sufficient beds in total in the state, but that there were only
a few counties that could show that there would be a need in that 5, 10, 15
year out window. There were only a
couple of those. So we did not do
anything at that time. And I think that
would—I think we’ve determined that that really might required legislation in
order to allow us to move beds from one place of the state to another.
JESSE SAMPLES:
This is Jesse again from the Health Care Association. I think that one of the things that we might
have to entertain is the standards themselves.
I know that when we looked at it before we were looking at population
over a certain age like we’ve done in the past when - - .
But that is a lot different than it was even just 10 or 15 years ago
with a lot of rehab services, which will account for that 15% Medicare
utilization just because there’s a lot more admissions and discharges in long
term care facilities than there used to be.
There’s probably a discharge rate to home of 30%, 35% in some areas
because they’re in short term rehab bed or short term rehab stays.
And so I
think maybe we could entertain something like just looking at the standards to
develop that need as to what maybe some of those projections would be. Certainly if you look at an area that has
continuous high census and waiting lists, again that there’s a demonstrated
need there, even though you could go back and look and say, well they only have
X number of population over the age of 65 or 75. That still may not determine a good way to
look at what the real need is in that community.
SONIA CHAMBERS: I
think one of the other concerns has been I think part of the—the reason for the
moratorium was the Medicaid budget since such a large percentage of patients
are funded by Medicaid. And I know that
Medicaid has periodically expressed concern about new construction and what
that might do to their overall budget because that is very definitely figured
into their reimbursement rates.
DEE KRAMER:
This is Dee Kramer with OFLAC.
Just to tack on to something that Jesse had said about facilities
gearing up towards Medicare and rehab to home.
There are also facilities that are choosing the Medicare admissions over
the long term Medicaid admissions. And
that’s been voiced as a concern to OFLAC Bureau for Medical Services and the
state long term care ombudsman program.
That people who need long term care placement forever, not for short
term rehab to home are not being able to get admitted into nursing homes.
SONIA CHAMBERS:
Because they’re full with short term rehab folks?
DEE KRAMER:
Because the facility is wanting to admit the short term rehab folks over
the long term Medicaid folks.
PHIL WRIGHT:
Because the Medicare rates are higher?
Is that it? I’m sorry, Phil
Wright.
DEE KRAMER:
They are higher. It is true, they
are higher.
PHIL WRIGHT:
Right.
DEE KRAMER:
In fact there are some facilities that will leave their beds open
waiting for a Medicare admission and decline Medicaid admission. Now that’s not something that OFLAC can investigate. But it is something that has been reported as
a complaint to OFLAC.
RAYMONA KINNEBERG:
This is Raymona Kinneberg. I
think that in terms of CON as a hole, most states have some function, even
states that don't have CON have a different kind of licensing process than
we’ve got here and look at the kinds of things that are looked at in CON in
terms of some of the financial implications.
These CON standards were written in 1982 and we’ve got some aging
facilities in this state that should probably
- - . But it probably would be a good idea for the
Authority to take under consideration revising the CON standards.
SONIA CHAMBERS:
For replacement facilities?
RAYMONA KINNEBERG:
Replacement facilities. You know
even for acquisitions - - .
JESSE SAMPLES:
This is Jesse. I think in order
to replace a facility, I mean it’s very difficult even in the acquisition to
actually replace a facility, which may be problematic. And what’s the exact working that if the
facility is like—
SONIA CHAMBERS:
[interposing] It has to be unsafe.
JESSE SAMPLES:
Yeah, be unsafe, that’s the word I was looking for. I think if we allow it to get to that point
then we haven't done the beneficiaries that utilize the programs justice there
if you have to wait until a facility becomes unsafe or so old that you can't
possibly renovate it before they have adequate facilities. One thing we didn't talk about as well was
the bed creep that used to be in place where if a facility had a certain
occupancy level for two or three years—I don't remember the exact timeframe—they
could add a certain percentage of beds onto their facility.
DAYLE STEPP:
This is Dayle. It was 10% of
their license each year.
JESSE SAMPLES:
Ten percent of their license.
DAYLE STEPP:
Once the moratorium went into effect…
RAYMONA KINNEBERG: The
language is where the unsafe part comes and that would require a law change, is
that right? Or even in the standards,
the new construction, you have to look at 95% of your residents are supposed to
come through - - . So that even if you’re looking at doing, such
as an Alzheimer’s or a hospice unit, you have let 95% of your people come from
that area. It’s part of what you have to
look at. And sometimes that gets a
little difficult, particular with the service areas being defined the way they
are. I think Kanawha [phonetic] County
has four separate service areas.
MALE VOICE:
I believe so.
RAYMONA KINNEBERG: And
so I think that another reason for the standards is to redo the definition of
what the service area is, assuming that we can deal with that unsafe
issue. Set up the way of evaluating
whether - - or a renovation project needs to be
done.
SONIA CHAMBERS:
Okay, why don't we go to—because we’re really not talking so much about
revising the standards at this point.
But I think after the resolution, whatever final resolution that any
legislation would take that you then go back and look at specific
standards. So I guess I’m interested in
entertaining comments about the laws related to CON. One, that it’s covered and two, the moratorium. And I would also say that you can speak today
and you can also submit any comments to us in writing. We would ask that you do that within 30 days
of our meeting and direct them to Dayle Stepp.
So with that, I’ll look for volunteers.
PHIL WRIGHT:
Sonia, a question, this is Phil Wright again. If I wanted to build a long term facility in
the northern panhandle or in central
SONIA CHAMBERS:
Well, you could not build new nursing home beds because there’s a
statutory moratorium.
PHIL WRIGHT:
There’s a moratorium, right.
SONIA CHAMBERS:
If you wanted to build an assisted living facility, there wouldn’t be a
prohibition here. You would go through
OFLAC and whatever other state licensure you’d need to go through. If you wanted to build a - -
care home, you could do that as well.
Right? It’s only if you wanted to
build a nursing home or add nursing home beds to an acute care hospital. Then you couldn’t do that.
PHIL WRIGHT: Phil
Wright again. I just personally don't
think it makes sense when the need changes so much. I know in the northern panhandle, there’s
shortages, there’s waiting lists. In the
southern part or the central part there may not be. But people don't want to take their loved
ones 150 miles and put them in a home and then have to travel back and
forth. I mean I don't understand why
it’s that way.
JESSE SAMPLES:
Phil, this is Jesse Samples again.
And one of the constant things, because I agree with you 100%. One of the constant things that was in place
20 years ago or 30 years ago as well as today that proximity is still the
number one determining factor--
PHIL WRIGHT:
[interposing] Oh, exactly.
JESSE SAMPLES:
--for people in placement in long term care facilities. That's what they want.
PHIL WRIGHT: A
few years ago I was trying to get my father in law in a nursing home and there
weren’t any beds. We had one heck of a
time getting him in a nursing home. We
waited and waited and waited. We brought
in nurses around the clock to the house for about three or four months and
finally we got him in. I just don't
understand why that occurs. And I don't
understand, the other thing I don't understand is if Medicaid and Medicare
control the reimbursement and if the state requires certain placements of
people in those beds, the individual home didn't have the authority to say no,
I don't know why you’re concerned with a CON.
SHEILA KELLY:
This is Sheila Kelly. I think
that part of the concern on this arose out of the advocates thought that
nursing home was being overused in preference to trying to support people in
their communities, in their homes and trying to use less restrictive or more
inclusive patterns of providing services to people, which was where the AD
waive the ages and disabled waiver program came into being and so forth and so
on. The problem becomes if you put all
your funding into nursing homes then that money is diverted from community
based systems of care. And I’m not
arguing for or against that argument.
I’m just saying I think that’s where the philosophical background of
that came from.
PHIL WRIGHT:
Yeah, well you’re not going to say no when someone has a need. So if you control the costs going in, you’ve
essentially controlled what you need to.
And controlling that cost is everything to me. It doesn’t matter if you have 150 nursing
homes or 30. The control of the pricing
mechanism is what dictates what the cost is.
You’re not going to put them in there if they don't need to be in there.
SONIA CHAMBERS: I
think Medicaid might argue with you that their methods for setting
reimbursement rates is not perfect.
PHIL WRIGHT:
Well then we have to make them perfect.
I just don't understand why we try to control when it varies in every
community differently depending on the age of the population at the time this
is occurring. And with the future
Medicare population coming on, I would think you’d want as many nursing
facilities starting construction as you could.
Controlling the price of that going forward so that they’re available
when they’re needed and not have these waiting lists and shortages. Just one point of view.
SONIA CHAMBERS:
Appreciate that. Who else? Pat?
PAT KELLY:
I’ll just reiterate what I sort of mentioned earlier. You have very objective standards that if the
nursing home facility has show a high occupancy rate of 95%, 97% for two or
three years, allow them to start adding some beds. - -
. I think you could expand on
your retirement center regulation and the law so that people could do the whole
continuum - - that the people once they’re in an area
they’ll have to then go two to three hours away for services. Life care retirement regulations are very
restrictive and they’re very hard to follow on
- - . And then finally I think
that more specialized units, that might be an area where we can increase the
number of beds and allow facilities to put in Alzheimer’s units and different
things of that nature.
PHIL WRIGHT:
Phil Wright again. The adjacent
states to
DAYLE STEPP:
This is Dayle. There are 37
states that have CON. They all review
long term care.
PHIL WRIGHT:
On long term care? Okay.
SONIA CHAMBERS:
Yeah, even some states that have—the only thing they review is long term
care.
DAYLE STEPP:
Right.
JESSE SAMPLES:
This is Jesse again, the CON process in and of itself doesn’t prohibit
additional beds. It is the moratorium
that is—
PHIL WRIGHT:
[interposing] Prohibiting it.
JESSE SAMPLES:
So you could still have CON or if you don't want to have CON you could
still have policies and procedures within DHHR that address the same issues as
to here’s what the criteria is in order to do whatever it is that you want to
do. But somebody’s going to review it so
that there is some type of review in that process.
PHIL WRIGHT:
If a facility though had 200 beds and you wanted to de-certify 50
because there was only 130 of them being used all the time, there would be
nothing stopping the state to do that, would there?
DEE KRAMER:
This is Dee Kramer with OFLAC.
And I’m going to jump in on what Sonia’s about to say. De-certifying it does not take those beds out
of circulation. Unless they’re
de-licensed, they’re still licensed.
PHIL WRIGHT:
Or de-licensing them.
SONIA CHAMBERS:
Well, and you can de-license beds now and that has occurred. I can think of at least, oh, three, four, in
the last couple of years, maybe more, that have de-licensed anywhere from what
ten beds—
DEE KRAMER:
[interposing] To 30.
SONIA CHAMBERS:
--to 30 beds. And they have done
that I think largely under Medicaid payment pressure. You think that’s fair to say?
DEE KRAMER:
That also means they’ve dropped below 90%, right, occupancy.
SONIA CHAMBERS: Well
that’s what I mean. At least that is
what I have heard from them anecdotally in those cases.
JESSE SAMPLES:
This is Jesse. I think there’s
probably two factors that go into that.
One is they’ve fallen below 90% occupancy. Another factor is available staffing. That staffing may not be available or they
can't attract the staff because of competition, so therefore they might not be
able to admit someone. And when they stop
admitting, they may fall below that standard.
So they look at it and say well, am I going to take the reimbursement
hit for being below 90% occupied, or do I just de-license the beds so that I’m
now kind of meeting the demand in the area or meeting the demand that I am
capable to staff. It’s probably more of
the former than it is staffing at this point.
But I think that, you know it is an issue in some areas and it will
probably become more of an issue as we go forward, particularly with other
options, whether it’s going to the—the home health care continuum relies on
those folks to deliver the service and they’re going to be in big demand.
NATALIE HOLLAND:
Natalie Holland, Genesis [phonetic].
I guess one of Jesse’s comments that we would support the inherent
discipline of a CON type program of policies and procedures. We would suggest that there - -
probably limited growth within facilities to help facilities meet the
needs of the immediate areas to - - areas.
Possibly, it may not be under our discussion today, the ability to
renovate facilities, which are aging across the state because in some
places - - the capital costs, limitation, et cetera,
place on doing that.
RAYMONA KINNEBERG:
This is Raymona. I think there’s
some interest in at least in construction projects looking at the capital cost
limit of 2 million given the dramatic increases of cost of construction -.
SONIA CHAMBERS:
How many facilities does Genesis own or operate in the state?
NATALIE HOLLAND:
- -
SONIA CHAMBERS:
Twenty-five?
MALE VOICE:
Plus some assisted living facilities.
MALE VOICE:
Does that include Wishing Wells?
NATALIE HOLLAND:
Yes, that does include - - .
MARILYN WHITE:
This is Marilyn. From the Genesis
standpoint, is the Medicare reimbursement pretty close to the same in all of
the different states where Genesis has got homes?
FEMALE VOICE:
- - considered part of the D.C.
Metro area
FEMALE VOICE:
- -
MALE VOICE:
11,202.
PHIL WRIGHT.
So it sounds like that seems to be a number that everybody can live
with, Medicaid, state Medicare. But you
don't have any flexibility with that number do you? You can't turn—when there’s a need in the
south you can't increase the number there and decrease it in the central or
north. I mean it just sounds like—
JESSE SAMPLES:
And Phil, this is Jesse. I think
that we might need to step back and do some work in terms of looking at the
ages and services that are being delivered or tended to in the nursing
facilities. As I said earlier, I’m not
sure that strict age over the beds per thousand for a particular just looking
at age is correct. Now we sill may not
come up with any additional need. But I
think that that’s an exercise that we would need to do to make certain. Because if the services that are being
delivered today, if it’s by looking at age of people and the services that are
being provided in the long term care facilities. One of the reasons that long term care
facilities are providing rehab services is because Medicare can cover those
rehab services in nursing facilities cheaper than they can pay for them in
hospitals and in hospital rehab facilities.
And that’s why the trend was to provide rehab services in nursing
facilities.
FEMALE VOICE:
[interposing] It’s not a moratorium.
Nobody has asked for them.
FEMALE VOICE:
To develop that care of bed you have to be able to demonstrate that it
can be - - .
MALE VOICE:
Those are LTAC [phonetic] aren’t they?
FEMALE VOICE:
They’re not nursing beds.
FEMALE VOICE:
Well that’s because you can't do ventilators in - -
without showing - - cost - - .
STEVE WEISMAN:
I appreciate the conversation today.
We’re very interested in working with the Developmental Facilities
Council - - . The national need for nursing homes in
general. We’re looking at other states
that have downsized - - and believe it’ll be showing up again. So I think the statement that was made in
2000 report that you all have on nursing beds by - - is
pretty much on the mark because it talked about
- - contingency on alternatives
being available. Our focus is on
alternative more so than more facilities.
Take what is - - not the approach that we advocate.
SONIA CHAMBERS:
Anybody else who’s on the phone wish to chime in? Suzanne?
SUZANNE MESSENGER:
I’m sorry, I had my phone muted.
I was just talking away.
SONIA CHAMBERS:
Would you like to say it un-muted now?
SUZANNE MESSENGER:
Well perhaps that might be a little more effective. This is Suzanne Messenger, state long term
care ombudsman. I guess I’d just like to
reiterate a couple of points that were already made. Generally the complaints that we receive from
consumers are not there there’s not enough beds but that there may not be
enough beds in the area of their choice, particularly for those consumers who
need what we might call specialized services.
Whether that encompasses Alzheimer’s care, ventilator services, some
residents who are morbidly obese, or even those suffering from traumatic brain
injury. Many of those folks cannot
receive services in a county of their choice in
The other
issue Dee mentioned with folks getting turned away because the reimbursement
source is Medicaid, we probably have two or three complaints at least every
quarter, possibly every month from someone who was told that the facility of
their choice had an open bed but that facility was holding the bed in favor of
a Medicare eligible resident rather than a Medicaid resident. So any changes to the CON process that could
address those concerns would be beneficial.
SONIA CHAMBERS:
Let me ask you this. How would
you deal with that?
SUZANNE MESSENGER:
Which?
SONIA CHAMBERS:
The facilities not taking Medicaid patients because they’re holding open
a bed for Medicare patients.
SUZANNE MESSENGER:
Well there’s probably a couple of different approaches. I believe there is language in our West
Virginia Medicaid manual that actually lists as a condition of participation in
the Medicaid program that if a person is otherwise eligible for nursing
facility services and qualified for Medicaid that they shall be admitted. And so perhaps a stronger reinforcement of
existing language may solve the problem.
SONIA CHAMBERS:
So let's follow that to its logical conclusion. What Medicaid would go—what would Medicaid’s
recourse be?
SUZANNE MESSENGER:
Well the ultimate recourse would be discharging the facility from the
Medicaid program. And I’m not proposing that or even advocating for that. That would be the logical end.
SONIA CHAMBERS:
Then you’d have less beds.
SUZANNE MESSENGER:
That’s exactly right. It would
not solve the problem.
SONIA CHAMBERS: I
mean I certainly understand the problem.
I guess I’m struggling with what might be the solution to that
problem. If they’re going to get…
MALE VOICE:
The difference of the Medicaid and Medicare rates as a penalty.
SONIA CHAMBERS:
Yeah, if they’re going to get more from Medicare, why—
SUZANNE MESSENGER:
[interposing] Certainly as a business decision, I mean it’s a logical
business decision. It’s just
discriminatory if I’m the person with—
PHIL WRIGHT:
Sure it’s discriminatory.
SUZANNE MESSENGER:
--receiving Medicaid and I don't really have a choice. It’s not like I can offer more. That’s what Medicaid’s going to pay, that's
all I’ve got to give.
SONIA CHAMBERS:
Well I would welcome anybody’s bright ideas on how to fix that one.
PHIL WRIGHT:
Do you even know when that occurs, Sonia?
SONIA CHAMBERS: I
don't think you’d know unless there’s a complaint.
PHIL WRIGHT:
Is there a method of complaints coming to you for those problems?
SONIA CHAMBERS: I
guess they come to Suzanne, right?
SUZANNE MESSENGER:
They come to the ombudsman program.
Sometimes the come to OFLAC.
Generally we haven't in the past referred them to the Health Care Authority. We certainly could if that’s information you’d
be interested in getting.
SONIA CHAMBERS:
No, I guess my question is more if there’s—I mean if we’re going to look
at anything statutory, or I would imagine Medicaid would be happy to hear
anybody’s bright idea on how to fix that problem.
JESSE SAMPLES:
This is Jesse. Do you ever
investigate a complaint like that and find out that it may be a
misunderstanding? For example, an open
bed is a male bed, it’s a female that’s wanting placement and of course you
have—
SUZANNE MESSENGER:
Certainly on occasion—
JESSE SAMPLES:
You can't co-mingle. I guess that’s a good word, thank you, Nora. I was looking for the word. You can't co-mingle the residents in that situation. Or maybe there was a bed that was empty but
it was in a bed hold for an individual?
SUZANNE MESSENGER:
Certainly on occasion what you’re saying is absolutely true. Not all those complaints are substantiated,
but many of them, the plain fact of the matter was the facility just told the
resident we’re holding this for a Medicare resident. Or they told the hospital discharge planner,
or they told the other, the doctor who was trying to place the resident. And because there is no recourse for that kind
of activity, it’s not a big secret. It’s
relatively easy to document.
DEE KRAMER:
This is
SUZANNE MESSENGER:
Correct. And it does not violate
a federal rule or regulation or our state nursing home licensure rule or a
statute.
PHIL WRIGHT: But a rule could be adopted by HCA for
the CON.
SUZANNE MESSENGER:
It certainly could be. And like I
said, I believe that there’s language in our state Medicaid manual already to
that effect.
SONIA CHAMBERS:
And that would be the more appropriate place for it.
MARILYN WHITE:
How much difference is there between the payments, the Medicare and
Medicaid, approximately?
PHIL WRIGHT:
It depends on where you’re at.
MARILYN WHITE:
Yeah, I know. I mean approximate,
that’s for
JESSE SAMPLES:
There probably is an average but I don't think I could just throw a
number out there because it could be all over the place.
MARILYN WHITE:
Are we talking hundreds of dollars do you think per day? I mean I don't think the Medicaid
reimbursement is $100 a day is it?
JESSE SAMPLES:
Medicaid reimbursement?
PHIL WRIGHT: Yes.
MARILYN WHITE:
It is?
PHIL WRIGHT:
It’s over. Yes.
MARILYN WHITE:
How much over, Phil?
PHIL WRIGHT: I
don't know the exact number off the top of my head but it’s over. They blend that number with something
else.
MARILYN WHITE:
Yeah, and maybe it’s gone up.
It’s been a while since I—
PHIL WRIGHT:
[interposing] Yes, it’s significantly over.
MARILYN WHITE:
Well and Medicare, does anyone have an idea what their average is for
PHIL WRIGHT:
It varies. I can't give you an
exact number. You’d have to average the
region.
MARILYN WHITE:
Private pay, what did you say the average for private pay would be?
MALE VOICE: I
just gave you an average of $190.
MARILYN WHITE:
And we know Medicare and Medicaid are certainly not going to be close to
that.
MALE VOICE:
Well that is the Medicaid.
MARILYN WHITE:
Oh, $190 is Medicaid. I’m sorry.
PHIL WRIGHT:
Yes.
MALE VOICE:
The total rate, which includes the resource amount.
MARILYN WHITE: I
misunderstood when you quoted that. I
thought you said that was the private pay.
PHIL WRIGHT:
No.
MALE VOICE:
And the average resource amount is $800 to $1,000 a month.
FEMALE VOICE:
This is - - geriatric center. There are facilities like ours that truly
gear themselves just to long term care residents, although we do have a small
Medicare - - that we’re not able to get - -
. On average we are only able to
admit one to two new residents a month because we’re truly long term care. - -
and therefore then people are on a waiting list - -
six months to a year sometimes waiting for a bed.
JESSE SAMPLES:
And this is Jesse, - - had a handful of beds, - -
continuum of care.
FEMALE VOICE:
- -
JESSE SAMPLES:
There was a period of time where people were in and out of so-called
skilled services. Maybe they need rehab,
maybe they need some temporary services.
And then they may be back in the home setting. We also provide home health services through the whole continuum and they
would - - not have to go, you know, to - - .
And they would have that continuity of care all the way through their
term.
SONIA CHAMBERS:
All right. Anything else? If not, thank you very much for your time and
your interest.
[END]