Tag Archives for Alfred Santos

Fix the Nursing Facility Problem Once and For All

Published in Pawtucket Times on April 28, 2003

Forty-years ago, the Senate Aging Committee hearings put the spotlight on the poor care provided in the nation’s nursing facilities.

This month, the April 2003 special issue of “the Gerontologist” sends the troubling message that nationwide improvement in nursing facility care is not likely.

Despite substantial regulatory oversight, Joshua Wiener, of the Urban Institute said “quality of care in nursing homes remains problematic. Quality of care in nursing facilities remains a problem for which there are not simple solutions.”

Before this national crisis can e directly confronted, increased staffing and raising the wages of nursing facility workers appear to be necessary preconditions for improving care quality and should receive high priority, said Weiner. (Rhode Island nursing facility providers hold similar beliefs and have called on Gov. Don Carcieri and state lawmakers to provide the necessary funding to raise facility worker’s wages.

The article’s written by 14 prominent policy experts in this special issue – “The Challenges in Nursing Home Care” – address central concerns in nursing facility care and help provide answers to questions, such as how these facilities can be financed and how care can be delivered.

The articles in this issue are the result of a conference held at Florida State University that was sponsored in part by the National Institute on Aging.

Dr. Quadagno and Dr. Stahl, guest editors of this special issue, believe a major challenge at both the national and state levels concerns the effective recruitment, training and retention of certified nursing aides.  Nursing aides, they pointed out provide about 60 percent of total nursing hours to residents (Again, this observation has been delivered to lawmakers at numerous legislative hearings on Smith Hill).

Many experts who wrote articles in this special issue contend the overall quality of nursing facility care in America still remains poor.  There are serious ongoing quality problems.

And like the rest of the nation, Rhode Island’s facilities are having problems recruiting and retaining certified nursing aids and providing higher wages to them as they receive inadequate Medicaid reimbursement.

What can be done about it?

Simply put, improving the quality of care in Rhode Island nursing facilities is directly linked to getting adequate Medicaid funding. The state must pay a fair rate when facilities are required  to provide quality care to 10,000-plus vulnerable Ocean State seniors who require intensive 24-hour-a-day care.

“The Principes of Reimbursement for nursing facilities are grossly underfunded,” charged Hugh Hall, president of the Rhode Island Health Care Association (RIHCA), a state-wide trade group representing nursing facility providers.

Hall, who is the administrator of the Cherry Hill Manor Nursing & rehabilitation Center in Johnston, estimated only two percent of the state’s nursing facilities are receiving adequate Medicaid reimbursement to cover their true costs of care.

Hall said that unless reimbursement is addressed swiftly, the quality of care delivered by facilities will begin to suffer the effects of the continued lack of attention of state policy makers.

“There is always another need for state tax dollars to be spent elsewhere,” Hall said, recognizing the growing number of special interest groups, who approach the General Assembly each year.

“Hopefully, it will be spent on where it is needed most, on the state’s frailest citizens,” he said, noting that “if the state does not spend it on them, who will?”

According to Alfred Santos, RIHCA’s executive director, the General Assembly is considering legislation (H 5803/S 0901) that would revise the state’s Principles of Reimbursement. Passage would begin to address the inadequate funding of the state’s nursing facilities, he said.

The legislative proposals, referred to the House and Senate Finance Committees, reflect the findings of an 18-month study of B.D.O Seidman, a consulting firm hired by the Department of Human Services to review and recommend fixest to the state’s flawed reimbursement system. Santos said one of the findings of this study was the state was underpaying facilities in excess of $ 30 million annually.

It’s time to fix the state’s flawed Medicaid reimbursement system once and for all. A Band-aid solution is not the appropriate approach considering the growing number of Ocean State seniors who will require higher levels of intensive care.

At an AARP  debate in gubernatorial candidates last September, this writer asked Carcieri if he would budget $ 15 million to overhaul the existing Medicaid payment system. The additional funding would greatly improve the quality of care and services provided to 10,000-plus nursing facility residents.

With this additional $ 15 million in state funding, the federal government would pick up another $ 15 million for a total of $ 30 million. This funding would allow Rhode Island facilities to provide quality care.

Candidate Carcieri acknowledged it would be difficult to find $ 15 million to fix the system because of the state’s looming budget deficit.

But there may be a light at the end of the tunnel. When the dust settles on the governor’s “Big Audit,” state funds may be identified and targeted toward ratcheting up the state’s inadequate reimbursement rate.

Combine these newly discovered funds with new tx revenues generated from the Lincoln greyhound track and you might just have the $15 million in state funds required to bring in millions of federal dollars.

For those Rhode Island seniors who are currently in nursing facilities, and for their children and grandchildren who may unfortunately require that intensive level of care, lawmakers must fix the payment problem once and for all.

Hopefully, Carcieri, along with the General Assembly, will not allow the B.D.O. Seidman report’s recommendations on fixing the state’s Medicaid payment system to sit on the dusty shelf in the Department of Human Services.

If that happens, what a waste of taxpayer money.

Governor’s Budget is Silent Regarding Many Senior Issues

Published in Pawtucket Times on March 24, 2003

Many of Gov. Don Carcieri’s policy initiatives can be found sprinkled throughout Fiscal Year 2004 Budget address.

While Carcieri’s 3,200-word speech identified his administration’s priorities – that is, maintaining human services, investing in education and creating jobs and fixing the state’s crumbling roads and bridges- it was silent on issues of interest to aging advocates and seniors.

At an AARP debate of gubernatorial candidates, Carcieri was asked if he would budget $15 million to overhaul the existing Medicaid payment system. The additional funding would greatly improve the quality of care and services provided to 10,000-plus nursing home residents.

With this additional $ 15 million in state funding, the federal government would pick up another $ 15 million, for a total increase of $ 30 million.

At the debate, Carcieri acknowledged it would be difficult to find $15 million to fix the system because of the state’s looming budget deficit.

After a first read, Alfred Santos, executive director of the Rhode Island Health Care Association, found the recently released administration budget did not allocate the $ 15 million in new funding to allow nursing facilities to be reimbursed for the actual cost of care that they provide to frail residents.

Santos hopes to schedule a meeting with Gov. Carcieri and his policy staff to discuss Medicaid reimbursement and staffing issues.

“One of the biggest disappointments for seniors in the governor’s budget is his failure to include funding to allow more low-income persons to choose Medicaid waiver-funded assisted living,” noted Maureen Maigret, who serves as Lt. Governor Fogarty’s director of policy and executive director of the state’s Long-Term Care Coordinating Council.

“This has been a priority for the senior advocacy community, and the governor was supportive of this funding during his campaign,” says Maigret.

Maigret told All About Seniors that more than a year ago, the federal government had approved an additional 180 units in the state’s Medicaid assisted living waiver to respond to Rhode Islander consumer demands.

“Failure to fund these units is short-signed in terms of saving taxpayer dollars and denies low-income seniors the option to choose a less restrictive care setting,” said Maigret, who calls the state’s current assisted living waiver program a great success.

According to Maigret, in the last fiscal year, there was a decrease in state-funded nursing home use of about 50,000 days and an increase in Medicaid funded Assisted Living of about the same number of days. “We have reached the funding cap for these Medicaid-funded assisted-living units and have a waiting list of 35 persons,” she said, noting that some of these persons will now be forced to enter nursing facilities at twice the cost of the state.

Meanwhile, Maigret added that the governor’s budget does not address the dire need of more regulatory staff in the Health Department to monitor assisted living and enforce state standards.

On the other hand, the Rhode Island Pharmaceutical Assistance for the Elderly Program (RIPAE) is intact, Maigret said.

“With the costs of prescription drugs increasing at such alarming rates, RIPAE is a vital safety net for thousands of Rhode Island seniors.

Maigret noted that changes this year in Blue Chip and United Health senior plans may further impact many seniors’ accesses to prescription drugs, as these plans have new features which limit benefits for brand name drugs. Legislation proposed by Fogarty and introduced by Sen. Elizabeth Roberts and Rep. Peter Ginaitt will address this pharmaceutical issue, she said.

Finally, Maigret said senior advocates must watch other areas of the state budget that will ultimately impact seniors. Some community grants, such as those that support senior centers, are targeted for 10 percent cuts. While nursing homes are in line for an annual cost of living increase (COLA) in their Medicaid rates, no similar COLA is included for home and community care providers.

Maigret added the governor’s budget cuts about $ 10 million (state and federal funds) to continue its efforts of downsizing the Eleanor Slater Hospital Cranston campus, with a proposal to close two more wards. To offset these closures, the budget includes about $ 800,000 to fund about 20 more nursing home placements and new funds to increase capacity to serve persons with mental illness in community residential settings.

The push to get residents back into the community concerns Roberta Hawkins, state ombudsman and executive director of the Alliance for Better Long-Term Care. She opposes the closure of wards because there are persons in the community who require a higher level of care, a level that is only available at the Eleanor Slater Hospital.

Hawkins noted the administration budget does not include Medicaid funding to pay for dental services to seniors in the community and those residing in nursing facilities.

“The short-sidedness of this fiscal policy ultimately will increase care costs when the resident must be hospitalized for malnutrition, dehydration and bed sores, all caused by dental problems,” Hawkins said. “On a human level, who would want to constantly suffer from pain all night because of a toothache or gum problems?” she added.

Sandy Centazao, president and CEO of Meals on Wheels of Rhode Island, is still waiting to see if Carcieri will ultimately institutionalize her nonprofit group’s funding rather than continue to allocate it as a legislative grant. She expects this decision to be made before the enactment of the state’s FY 2004 budget on July 1.

With a looming recession and a nation at war, Carcieri and the General Assembly must ultimately make difficult decisions as to how to slice the state’s FY 2004 budget. The state’s final budget must  provide the funding and adequate resources to enable long-term care providers to take care of the state’s burgeoning older population. It’s the right thing to do, even n times of uncertainly.

Rhode Island Nursing Homes Scramble to get Dental Coverage for Residents

Published in Pawtucket Times on March 3, 2003

According to Alfred Santos, executive director of the Rhode Island Health Care Association (RIHCA), one company’s business decision has left Rhode Island nursing homes scrambling to bring dental coverage to thousands of nursing home residents.

Over the last two months, Santos has met with state regulatory officials to inform them of this latest health-care access problem.

Here’s the scoop:

Access Dental Care, a major provider of dental services to nursing facilities, announced in a Nov. 4 member to its 40 nursing home clients that it would no longer offer onsite dental care, beginning Jan 1, 2003. The brief memo cited the extreme physical challenge to dental staff who provided dental services to residents outside the normal dentistry setting as the rationale for dropping onsite dental care.

But a nursing home trade group says that there may be a bigger issue behind Access Dental Care’s decision to not provide onsite dental services to nursing home residents.

RIHCA’s Dental Services Committee believes the actual reason for this business decision may well be tied to a low Medicaid reimbursement for dental care services, said Chair john Gage, who also serves as the trade group’s vice-president. Currently, Gage is the administrator at Riverview Heatlh Center in Coventry.

Gage said 80 percent of nursing home residents rely on Medicaid to pay for their dental services. Access Dental Care’s decision to not perform dental services on site will force m any frail, bedridden residents to be transported outside the facility for treatment, causing needless pain and suffering to them, he said.

“With a severe staffing shortage facing many facilities it will be even more difficult to assign a staff person to accompany the resident,” Gage noted.

According to Gage, it’s not so easy for nursing homes to find other providers to deliver onsite dental services. Complicating this health care access issue, Geage said, is HealthDrive’s policy not to contract with any nursing home to only provide dental services.

At press time, state officials from the Department of Health and Human Services were unavailable for comment about this payment issue.

State Sen. H. Elizabeth Roberts

(D-Cranston), who is chairing a subcommittee of the state’s Long-Term Care Coordinating Council (LTCCC) is currently looking at Medicaid issues, said Access Dental Care’s decision to not provide treatment to Medicaid recipients in the nursing home setting only exacerbates an ongoing problem. That Is, low Medicaid reimbursement  keeps low income seniors from receiving the appropriate preventative and restorative dental care they need.

Roberts said, “inadequate Medicaid rates make it hard for dentists to see residents, because the rates are so far below their costs. When combined with the medical complexity of nursing home patients, the low reimbursement is even more of a barrier, she said.

Robert’s LTCCC subcommittee plans to turn their attention to investigating the obstacles that keep dental care from being provided to Medicaid-eligible seniors in nursing homes and in their homes.

Bringing dental services to low-income children and seniors became an important issue to Roberts when care to a young constituent in the Rlte Care program required the use of an operating room for dental work because of severe tooth decay.

This operation could have been prevented with ongoing dental care, she said, noting that it “took the attention of state government to locale a provider who would accept the low Medicaid provider rate.”

Roberts is working to ratchet up the Medicaid reimbursement for dental care and to streamline the payment process through legislation she has recently introduced. The senator intends to bring together the state’s Dental Society and nursing homes to develop a plan to bring dental care to facilities that no longer received onsite dental service.

Robert Hawkins, state ombudsman and executive director of the Alliance for Better Nursing Home Care, agreed with Roberts’ assessment that there has been limited access to dental services in nursing homes over the past couple of years.

Hawkins has been pushing for appropriate dental treatment for nursing home residents for more than 25 years.

“Medicaid-eligible seniors who are mobile can more easy travel to dental clinics, if they can find treatment, especially with the low Medicaid rates,” Hawkins said. “For the old, sick and feeble, why should they have to go to through the turmoil of leaving the facility to get their dental care?

“Lack of access to dental care is a form of discrimination for those unfortunate to be lower-income and on Medicaid, Hawkins charged.

The Medicaid system has always been “penny wise and pound foolish,” Hawkins said. “When you don’t treat a dental problem early, residents don’t eat, they lose weight, develop bed sores, ultimately requiring costly hospital care.

“Can any one remember having a tooth ach all night long with no where to go?,” Hawkins asked.

Susan Sweet, a consultant to nonprofit groups and a longtime elder rights advocate, added there is also a lack of dental care for low-income seniors that extends into the community as well.

“For some reason, dental care is treated in the health care community as less important as other medical care,” she said, adding that reimbursement for dental care has lagged behind reimbursement for other medical care.

So where do we go from here?

Roberts’ plans to bring the state’s Dental Society together with nursing homes to craft a short-term solution is the first step in removing the obstacles of providing dental services to Medicaid-eligible residents. But a more permanent solution is needed.

With Gov. Don Carcieri poised to shortly release his budget, I hope he and the General Assembly counter Medicaid’s traditional “penny wide and pound foolish,” philosophy by increasing Medicaid payments for dental services. An inadequate reimbursement rate will ultimately reduce the needless pain and suffering that dental problems cause in nursing homes across the state.