Long Term Care Community Coalition

Consumer Participation In Nursing Home Medicaid Reimbursement Policy Making

Importance of Consumer Participation

Medicaid is the major purchaser of nursing home care in the U.S. It is a significant area of concern for state and federal officials trying to balance their budgets. It also is a significant area of concern for nursing home residents and providers. Although resident advocates have been successful in influencing major changes in both nursing home rules and regulations and in encouraging culture change, few have been involved in the development or modification of state methods for reimbursing nursing homes.

Without doubt the interests of advocates may differ from those of state officials and nursing home industry representatives. In general, industry representatives prefer to maximize payment and flexibility under state methods for reimbursing nursing homes. This is in contrast to advocates who while also tending to favor maintaining payment levels, prefer that systems be promulgated that incentivize quality by holding providers accountable for performance and outcomes.

States typically employ taskforces when making major changes to the way nursing homes are reimbursed under Medicaid. In most cases, membership rarely includes consumers/residents’ advocates, perhaps because policy makers believe they have less to offer or do not have the expertise to “be at the table.” And, when at the table, consumers/residents’ advocates participation tends to be less consequential given their prevailing lack of interest and expertise in this area. Where sufficiently influential, providers have proven successful in steering state reimbursement in such areas as provider taxes, capital valuation, cost reports, and wage mandates toward their interests.

Evidence suggests the importance of including the voice of consumer advocates in state reimbursement policy discussions. Lack of consumer involvement has the potential to result in the adoption of reimbursement systems that favor industry and government interests at the expense of issues important to residents and their families: access, care quality, and quality of life. Lack of consumer involvement also has the potential to result in less creative changes to state reimbursement systems than might otherwise have been possible.

The Commonwealth Fund funded this project as a collaboration between LTCCC and the University of Massachusetts to both increase consumer involvement in Medicaid nursing facility reimbursement policy making and to convince policy makers of the importance of consumer involvement. Products of this project are below.

A Primer for Consumer Involvement in Medicaid Nursing Facility
Reimbursement: Lessons from New York and Minnesota

The purpose of this brief is to detail the lessons learned, to both encourage and assist the consumer advocate, in his/her participation in developing and implementing state policy on Medicaid nursing home reimbursement. Several strategies are identified for successful advocacy in this area. We believe this will be useful as advocates across the nation advocate for reimbursement systems that favor the interests of current and future nursing home residents and their families.

Consumer Involvement in Medicaid Nursing Facility Reimbursement:
Lessons from New York and Minnesota for State Policymakers

The purpose of this brief is to draw lessons from case studies of New York and Minnesota to convince state policymakers, to reserve room “at the table” for consumers and their representatives when Medicaid nursing home reimbursement is being discussed, developed and implemented and to convince them this will further the promulgation of reimbursement systems with attributes that more effectively promote the welfare of current and future nursing home residents and their families.

Final Report: Increasing Consumer Involvement in Medicaid Nursing Facility
Reimbursement: Lessons from New York and Minnesota

This report describes the methodology, why consumers are not "at the table," the prerequisites for being "at the table," strategies for influencing policy as well as resources used in the project.

Webinars for Consumers: Understanding Medicaid Nursing Facility Reimbursement

Title: Increasing Consumer Involvement (Introduction & Module 1). This presentation provides an introduction to the online seminar series on increasing consumer involvement in Medicaid nursing facility reimbursement, in addition to the first module in the series, which provides an overview and establishes the importance of the topic.

Title: Increasing Consumer Involvement (Module 2). This is the second module in the online seminar series on increasing consumer involvement in Medicaid nursing facility reimbursement. It reviews the nuts and bolts of Medicaid policy in this area.

Title: Increasing Consumer Involvement (Module 3). This is the third module in the online seminar series on increasing consumer involvement in Medicaid nursing facility reimbursement. It reviews the methodology used in this study, consumer participation and influence, the importance of being at the table, and prerequisites for successful consumer involvement.

Title: Increasing Consumer Involvement (Module 4). This is the fourth modules in the online series on consumer involvement in Medicaid nursing facility reimbursement. It reviews major strategies consumers in Minnesota and New York have pursued to influence state policy in this area.

Title: Increasing Consumer Involvement (Module 5) and Conclusion. This is the last module in the online series on increasing consumer involvement in Medicaid nursing facility reimbursement. It reviews some potentially effective supplemental strategies consumers have pursued when trying to influence Medicaid nursing facility reimbursement. It also presents the overall take away lessons from the series.
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Previous Study of Nursing Home Reimbursement Policy Making

With funding from the New York Community Trust, LTCCC undertook a study on case-mix reimbursement, the system of paying for nursing home care utilized by the majority of states, to identify and assess how each of these systems is structured and the impact of that structure on: quality of care, access to care for individuals with higher needs and the efficiency in the use of public funds. Project goals were to: (1) identify how states can modify their nursing home case-mix reimbursement systems to better encourage quality care, access and efficiency; (2) relate nursing home reimbursement to inspection and enforcement; (3) relate nursing home reimbursement to quality outcomes; and (4) respond to the specific budget proposals in our home state, New York State, as the it identifies, assesses and implements ways to modify its reimbursement system, so that it better achieves the goals of quality and efficiency in the face of the current economic crisis. In order to accomplish these goals, LTCCC: gathered detailed information on the characteristics of each of the 35 states using a case-mix nursing home Medicaid reimbursement system; surveyed state ombudsmen and representatives of citizen advocacy groups; selected seven states for in-depth analysis as case studies; and interviewed state officials from these seven states. All this information is detailed in the final report, released in 2009, with specific recommendations for change.

 

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