Medicaid is the major purchaser of nursing home care in the United States. States design their methods of reimbursing nursing homes to achieve desired policy objectives related to facility cost and quality, access to care, payment equity, service capacity, and budgetary control. The incorporation of multiple, sometimes conflicting incentives into state reimbursement systems has resulted in enormously complex and demanding methodologies that inhibit consumer participation in state rating setting decisions. In turn, the 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. All stakeholders, including consumer advocates, must be at the table when reimbursement policy is being discussed.
Now is the time to be planning how to take advantage of several provisions within Patient Protection and Affordable Care Act (ACA) of 2010 related to provider reimbursement where implementation would benefit from consumer involvement. One example, the National Pilot Program on Payment Bundling, will combine payments for hospitals, physician, outpatient, and post-acute care into a unified payment for ten specific chronic conditions. Elsewhere in the ACA are a number of Medicare value-based purchasing/payfor-performance provisions which require the development of plans to implement valuebased purchasing for nursing homes and home health care providers as well as to pilot test pay-for-performance for other providers, including long-term care hospitals, rehabilitation hospitals and hospice. What strategies should consumers pursue to influence these and other similar endeavors?
New York and Minnesota are two states where consumers have been successful in influencing the development and implementation of Medicaid nursing home reimbursement policy to better encourage access, care quality, and quality of life. To understand how consumers can acquire a seat at the table and be effective in influencing payment policy, 24 in-depth interviews were conducted with 27 individuals in these states with known or demonstrable experience in this area. Subjects interviewed include: state agency officials, state legislators and legislative staff, consumer advocates (including ombudsmen), union staff, and nursing home industry representatives. Pertinent documents were reviewed as well. The primary purpose of this report is to detail lessons learned from New York and Minnesota about how best to promote effective consumer involvement in the reimbursement of nursing homes and other long-term care providers.
Miller, Edward Alan and Rudder, Cynthia, "Increasing Consumer Involvement in Medicaid Nursing Facility Reimbursement: Lessons from New York and Minnesota" (2012). Gerontology Institute Publications. Paper 69.