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Coming to a State Near You, "Reduced" Medicaid-Funded Nursing Home Care

Alexa's picture


I ran across the Kaiser Health News piece referenced below, while I was researching another topic. The policy "reform" that this piece addresses hits home for me, since we have a number of close relatives who live there, and spend several months each year in Tennessee.

In my opinion, this groundbreaking and truly pernicious policy is not likely to be "contained" in the state of Tennessee. It is the result of a federal test pilot program conducted under the auspices of the [Patient Protection and] Affordable Care Act (ACA). This "new category" of patient has been approved by both the Tennessee State Legislature, and the Obama Administration's Department of Health and Human Services (HHS).

I find it to be nothing short of abhorrent that we as a society, will accept allowing some of our most elderly, sickly and frail citizens to (possibly) be forced to lie in their own excrement, in order to "save a buck."

The idea that folks who cannot perform two or more of the Activities of Daily Living, or ADLs, can "get by" with no more than an occasional “visit” (or for that matter, a 4-hour, 5 day-a-week visit) from a home health care aide, is absolutely ludicrous. [The six (6) types of ADLs, are: Eating, Bathing, Dressing, Toileting, Transferring, and Maintaining Continence.]

Now is the time to fight this regulation, before it spreads to other states. Please help get the word out. If you see an opportunity to post a hyperlink to the original news article, please do so. Tennessee is still considered a "purple state," by some. You can bet that other states (especially "red states") will adopt this policy, if there is no organized pushback.

Here's an excerpt, and hyperlink to the full article, below:

In a unique experiment being watched nationally, Tennessee is revising its Medicaid long-term care options to make it harder for certain low-income elderly people to qualify for state-paid nursing home care.

The program, which has received federal approval and began this month, is the first of its kind in the nation because it creates this new category of patients who don’t qualify for nursing home care. Up to now, under federal law, everyone who receives long-term care under Medicaid first had to qualify to be admitted to a nursing home.

"Federal law requires that program eligibility be tied to eligibility for nursing homes," said Matt Salo, executive director of the National Association of Medicaid Directors. "Tennessee is stepping ahead to create this new category of at-risk individuals whose benefits are not linked to nursing homes."

But consumer advocates worry that the $15,000 annual limit will fall short of meeting the needs of some seniors, who could end up going without services or relying on funds from family or friends. Gordon Bonnyman, executive director of the Tennessee Justice Center, said he feared that "a lot of frail people are not going to make it on the reduced package."

The average cost per year for nursing home care nationally is about $80,000.

State officials decided they could raise the level of need for patients to qualify for full long-term benefits, whether in a nursing home or elsewhere. The legislature approved the change in April, as did the federal Centers for Medicare & Medicaid Services.

Under the new regulations, the current requirement – that someone need help with an "activity of daily living" such as dressing or using the bathroom – has been replaced by a complicated weighted point system that makes it considerably more difficult for patients to reach the standard to qualify for nursing home care.

Jesse Samples, executive director of the Tennessee Health Care Association, representing the majority of Tennessee’s 330 nursing homes, agreed [with Bonnyman] that TennCare’s chief motivation is to save money and also agreed with Killingsworth that nursing homes were the target.

"In an ideal world we would increase funding for all categories of services," Samples said. "But we’re playing a zero-sum game here. In order to get money for home and community-based services, you have to take it from somewhere else. That would be nursing homes."

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NWLuna's picture
Submitted by NWLuna on

but why do I think it will not?

Many people in SNFs (skilled nursing homes) do not need the entire package of care, but there are few models for community-based care to ensure persons receive what they need without dangerous shortcuts.

In Washington state there is something called "RN delegation," which allows registered nurses to delegate certain tasks to non-licensed care aides, if those tasks can be safely performed by the unlicensed personnel. Sounds good in theory -- allows lower-paid staff to care for elders and disabled adults in community settings. However, there is not enough oversight. Untrained staff are giving out meds without knowledge of pharmaceutical mechanism of action, side effects, or warning signs. Unskilled staff will transfer patients/residents from bed to wheelchair by dragging them across the bed, so frail skin gets abraded and torn, leading to pressure ulcers ("bedsores") and infection and pain. I could go on.

There are some places in which good care is provided. Staff there know their limits and will call the patient's attending clinician about symptoms or with questions. For a while I had my own practice visiting adult family homes and other community settings to provide primary care to elders and the disabled. But there needs to be a robust network of care services available, not just one PCP (besides I hate to do my own accounting). Some places are atrocious and need to be reported to the state board of health, which is sadly underfunded for investigations. Many places are just mediocre.

We could take a bit out of the funding for the war(s), and instead fund some good home-based care models with appropriate staffing and oversight. Or ....

We could be surprised by what Tennessee does. I wonder....what could possibly go wrong? Is there enough oversight and staffing available? I hope we will not be shocked.

Alexa's picture
Submitted by Alexa on

reference Medicaid "reform" in Tennessee. It is great to hear from a health care professional (which I am not).

I won't rehash the information above. Here's a brief excerpt from the original Kaiser Health News piece:

The new program is the second time in three years TennCare has moved to reduce use of nursing homes. In 2009, the state obtained permission from the federal government to offer nursing home patients—and new long-term care enrollees—the option of receiving care in a family- or community-based setting. Under that program, nursing home care would only be required if the alternative setting could not meet the patient’s needs or if the cost of those needs exceeded the $55,000 per year.

That change has been successful. In 2010, around 83 percent of Tennessee’s long-term Medicaid patients were in nursing homes, with 17 percent in home and community settings under a prior waiver. Today, 66 percent of patients are in nursing homes and 34 percent are receiving home- and community-based services.

Dr. Melinda Henderson, executive director at the UnitedHealthcare Community Plan, one of three managed care organizations that administer Tennessee’s Medicaid system, said patients overwhelmingly choose not to be in nursing homes.

Now, the alternative program described above (with a cap of $55,000 per year) sounds feasible, affords the state a decent savings, and would most likely please less incapacitated seniors, without compromising their health.

I will closely follow this new "standard" and program. Maybe I will be pleasantly surprised--I hope so.