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Long-Term Care Providers Voice Concern About Costs From New Rule

By Rebecca Adams, CQ Roll Call

July 13, 2015 -- The long-term care industry voiced concern about the cost of complying with a 403-page rule that proposed the first comprehensive updated requirements for facilities in 24 years. The proposal was published in the Federal Register early last week.

During the first year, the industry is expected to pay more than $729 million to meet the new requirements and about $638 million per year after that. The average cost would be $46,491 in the first year for each of the 15,691 long-term care facilities affected by the rule and $40,685 per facility in later years, according to the Centers for Medicare and Medicaid Services (CMS).

"We would oppose such a large unfunded mandate, especially given the overall narrow margins of 1 percent to 3 percent that MedPAC calculates for skilled nursing care centers," said American Health Care Association Senior Vice President of Quality and Regulatory Affairs David Gifford, referring to Medicare Payment Advisory Commission calculations.

Gifford said that the industry could support some of the changes in the rule because many nursing home and other long-term care facilities have already incorporated similar changes. But the costs are a major concern.

"We are still working through it to see what we support and what we do not support. CMS estimates the cost to comply is significant," said Gifford.  "We will need to examine to see what parts of the rule increase operators' costs and if there are alternate, more efficient ways to comply."

Consumer advocates want more requirements in the massive rule, which notes that the way that skilled nursing homes and other facilities operate has changed significantly since the rules were last updated in September 1991.

The National Consumer Voice for Quality Long-Term Care and the American Association for Justice, which represents trial lawyers, met with Office of Management and Budget officials on June 19 to ask that the rule include specific ratios of staff per patients so that there would be enough staff members to take care of the residents, many of whom are frail. The groups asked for requirements that nursing homes or other facilities provide for at least 4.1 hours of direct nursing care per resident and have at least one registered nurse on duty at all times. The coalition said that certified nursing assistants should have at least 120 hours of initial training.

But the rule does not include those requirements.

"We note that some commenters requested changes that conflicted directly with statute," the rule states, regarding concerns about staffing levels.  "Moreover, some of the comments we received were outside the scope of our review...However, we have shared all of the stakeholder's comments with appropriate CMS staff for their review."

The differing perspectives of the groups are likely to be incorporated in comments to pressure CMS to change the proposal. CMS officials are accepting comments for 60 days. The agency said it had already received input from about two dozen groups that knew CMS was working on a rule.

The regulation would affect a wide range of issues, including hospital admissions, efforts to reduce the use of antipsychotic medications, initiatives to prevent infections, the expansion of residents' choices in mealtimes and living conditions, new credentialing requirements that physicians be licensed to practice medicine in the state, visitation rights and new standards on mental health care.

The rule would require patients to receive an in-person evaluation by a qualified medical professional before being transferred to a hospital and that a patient's physician be notified before the resident is sent to a different facility.

White House Conference

The proposal was released on the same day that the White House held a national conference on aging where officials announced a series of other initiatives related to the aging of the population. Those include:

  • Updates to the Department of Health and Human Services' national plan to address Alzheimer's disease to reflect actions that the government will take over the next year.
  • A National Institutes of Health workshop on elder abuse research featuring researchers, clinicians and others.
  • An online course launched by the Centers for Disease Control and Prevention offering continuing education credits to medical professionals about how to make falls prevention a routine part of care.
  • The Health Resources and Services Administration will award $35 million to health profession training programs to expand geriatrics education to prepare the health care workforce to respond to the needs of an aging population.

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