As the State of Wisconsin transitions to a new LTC system, WAHSA suggests a number of changes could be implemented in the near future to improve the current LTC delivery system. As previously stated, some believe these changes could take the place of the more comprehensive system reforms which rely heavily on the utilization of MCOs and larger networks.
In our opinion, the single most important element needed to improve an already good LTC system is the creation of a LTC data system. DHFS should develop a uniform comprehensive assessment and evaluation data system for all LTC clients. Done correctly, this system would provide significant improvements in the way services are currently delivered, financed, and evaluated.
Long term care policy makers presently lack the necessary data to make informed decisions regarding proposed system changes. The paucity of critical data has resulted in a lack of clear, unified policy-making within the Department. We can cite several examples. A DHFS' briefing paper presented to Secretary Joe Leean states that "based on the 1994 nursing home survey, more than 3,000 nursing home residents admitted that year were totally independent in the reported activities of daily living (mobility, transferring, locomotion, dressing, eating, toileting, and hygiene) at the time of their admission."9 The clear implication given is that these 3,000 residents were inappropriately admitted to facilities. That may or may not be accurate. That is, the Department has not reported, apparently because the data does not exist, whether these residents were admitted to address behavioral symptoms or a developmental disability (county facilities typically serve residents with complex behavioral symptoms) nor how long their length of stay was. In other words, were these unnecessary admissions? For DHFS to pursue rational LTC policies, it must first implement better data collection and analysis systems.
Of greater concern is the lack of data on the cost effectiveness of services offered throughout the current LTC system. For example, State law requires the Department to submit annually to the Legislature a report of the cost and services in the Medicaid home and community-based waiver programs, CIP II and COP-W. And, annually, this report concludes that these programs are significantly less costly than the cost of serving persons in skilled nursing facilities. However, in recent years some have questioned the accuracy of these reports due to the apparent lack of comparable data among the programs.
In April, 1995, two researchers from the University of Wisconsin issued a report which reviewed community-based long term care initiatives with an emphasis on Wisconsin's Community Options Program (COP). Dr. Mark A. Sager, MD, and Dr. Greg Arling, Ph.D., reviewed the national research on community-based long term care programs (CBLTC) and concluded:
The report goes on to make the following observations specific to Wisconsin's COP:
Although some questioned the findings of this report, eighteen months later, the Department's own Office of Strategic Finance, Strategic Planning & Evaluation Section, also released a report which concluded that nursing home residents:
And finally, Joshua M. Wiener of the Urban Institute recently published research sponsored by The Commonwealth Fund in which he notes:
We offer these extensive remarks on the need for data and cost-effective decision-making because we are under no illusion that the State of Wisconsin will pursue LTC reform measures other than those that control the rate of increase in overall Medicaid and LTC program expenditures. However, absent reliable program, assessment, and fiscal data, DHFS will not have the necessary tools to meet this desired outcome. One should not construe our references to the above studies as an attempt by nursing homes to "circle the wagons." In fact, WAHSA favors a system in which nursing home residents who can be served more cost-effectively in alternative settings be given that opportunity.
What we are suggesting is that all LTC programs be carefully scrutinized for cost effectiveness and customer satisfaction and that no assumptions be accepted until the data necessary to confirm these assumptions is collected and properly analyzed. A uniform comprehensive assessment system which sets capitation rates for all LTC clients (a system in which the dollars follow the consumer) would create, we believe, many more options compared to today's choices.
DHFS should undertake an extensive review of its LTC regulations and eliminate those which unnecessarily favor one provider group over another.
Under a redesigned system in which clients have greater care and service options, and capitation payments are determined according to comprehensive assessments, many regulations would become obsolete. For example, WAHSA questions the future need for: limiting COP funding for CBRFs; restricting the use of Medicaid waiver funds for facility-based adult day care programs; much of HFS 83 and Chapter 150 (as it relates to the cost per bed limitation which forces many facilities to continue to utilize semi-private rooms); and restricting the use of single task employees and unlicensed staff in certain limited supervised settings. Further, DHFS should encourage the development of accreditation programs throughout the LTC spectrum as a way to foster innovative QA monitoring programs.
WAHSA also supports the following changes to the current long term care system:
WAHSA 204 South Hamilton Street Madison, WI 53703
Telephone: (608)255-7060 FAX:(608)255-7064