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:

• "In essence, CBLTC was assumed to be more cost-effective than nursing home care, i.e., it could provide similar or better care at a lower cost. From a budgetary standpoint, CBLTC programs presumably could be implemented without additional public expenditures and, in fact, they might even result in cost savings. Unfortunately, after nearly two decades of experimentation, various approaches to CBLTC demonstrations failed to reduce nursing home or other health service use; they added to public LTC expenditures rather than reducing them; and they had only minimal effects on the health, functional status, or well-being of older persons participating in the programs"10

The report goes on to make the following observations specific to Wisconsin's COP:

• "The limited data that are available from COP suggest that COP clients may have fewer care requirements (lower level of care and less likely to be terminally ill) than nursing home residents. Yet, it is the more dependent and medically unstable individual who is at greatest risk of nursing home admission. The State has reported lower average costs for COP/COP-W clients when compared to nursing home users. Yet, these comparisons may not be valid because the they fail to adequately adjust for potential differences in care needs between the two populations. Unfortunately, information is not available with which to make accurate cost comparisons between community and institutional settings (emphasis added)."11

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:

• "tend to show more adverse conditions, functionally or mentally, than their community waiver counterparts. Relatively more nursing home residents are at a higher level of skilled nursing care need, have many more functional impairments in activities of daily living such as bathing, dressing, eating, toileting, and transferring between surfaces, and show signs of memory loss or cognitive problems. They are also more likely to exhibit problem behaviors, show signs of mental distress, and have problems with incontinence."12

And finally, Joshua M. Wiener of the Urban Institute recently published research sponsored by The Commonwealth Fund in which he notes:

• "The most persistent hope of long term care reformers has been that the expansion of home care and nonmedicalized residential settings could reduce overall long term care spending, and states such as Washington, Wisconsin, and Oregon have been active in reorganizing their long term care delivery systems. However, a large, rigorous research literature suggests that expanding traditional home care is more likely to increase rather than decrease total long term care expenditures, in part because home care for nursing-level persons without extensive family supports is expensive. Acknowledging these problems, Oregon has developed an alternative strategy of expanding nonmedical residential alternatives, such as assisted living and adult foster care. As of yet, no systematic, rigorous cost study has been performed."13

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:

• Reimbursement for all LTC services should reflect the acuity/service needs of clients. Payments under COP and nursing homes should reflect resource allocation principles, adjusted for case-mix.
• DHFS should pursue the option identified in its September 18, 1995 LTC concept paper which suggests the buy-out of surplus nursing home beds.14
• DHFS should increase efforts to close poor performing providers throughout the LTC spectrum.
• DHFS should implement quality assurance monitoring systems throughout the LTC spectrum, including both residential and nonresidential settings.
• Funding limits imposed on clients should reflect maximum expenditure levels based on a comprehensive assessment, not on the average cost of nursing home care. Assessments and care plans should be updated regularly and evaluated. DHFS should utilize progressive recipient cost-sharing provisions to maximize the availability and cost-effectiveness of publicly funded services.
• DHFS should act to maximize third party payments and allowable federal financial participation for all programs (e.g., ITP funds, client and resident share, and Medicare billings).
• The State of Wisconsin should actively promote the purchase of group and individual long term care insurance policies through taxation and policy modifications.
• The measure of success in evaluating Wisconsin's LTC system should not be based on the type of care and service providers utilized under this system. Instead, the system's success should be determined on whether it "maximizes an individual's choice of services, providers, and care settings as long as such care is necessary and meets a minimum level of quality standards and is cost-effective."15