When the 84th Texas Legislature convened in January, officials with the Health and Human Services Commission told lawmakers that long-term nursing care for Medicaid recipients in the state had a $343 million funding hole. Five months later, a study of Medicare quality data by the Kaiser Family Foundation found Texas had more one- and two-star long-term care facilities than any other state in the country.
By the time the legislature adjourned sine die, the $61.2 billion budgeted over two years for Medicaid didn’t include more funds for long-term care. Too, primary care providers didn’t receive a bump from the state that would’ve matched a federal increase that recently expired. Because of that, Medicaid reimbursement rates went from paying what Medicare did to paying just 65 percent of it.
And now, elder care advocates are growing increasingly worried that the problems that have come to the surface in providing care to the elderly will be exacerbated: The difficulty in recruiting, consistent staffing, and finding doctors who will take Medicaid patients despite low reimbursements.
“One of the keys to improving care delivery is consistent staffing and having capable and available staff that can care for the needs of the population,” said Kevin Warren, president of the Texas Health Care Association, which lobbies for about 500 long-term care facilities. “It is extremely difficult and challenging work. It is difficult to compete with other healthcare sectors.”
Census figures project the amount of residents 65 and older to go from 2.6 million in 2010 to 9.4 million in 2050. Currently, about 80 percent of this population is enrolled in Medicare or Medicaid. And reimbursements in Texas are among the nation’s lowest. A report commissioned by the American Health Care Association found that homes in Texas were reimbursed an average of $133 a day per patient, the worst in the nation.
“There’s not a whole lot of alternative options in long term care to seek alternative methods of reimbursement,” Warren said. “This is something we’re going to have to take a look at downstream to figure that out. In the mean time, facilities across the state are having to work diligently to figure it out. How do we work within the means we’ve been given?”
The Legislature did enact controversial legislation that will mandate that the HHSC revoke the license of a convalescent or nursing home facility after three violations in a two-year period. The Texas Health Care Association says it doesn’t address the “root problem” of the violations—poor reimbursements, short staffing, trouble with recruiting and retention—and could put seniors at further risk.
“Retention, that’s a challenge with recruitment. It’s hard work, and I think that’s one of the key things that we hoped (the legislature) was going to do,” Warren said. “We will continue to communicate with them to make it a priority in the future.”
Practitioners who see the elderly outside of a nursing home have more ways around the reimbursement struggle, says Dr. Youceff Sennour, a former president of the Texas Geriatric Society and a practicing physician at the Baylor Geriatric Center. He prioritizes patients by acuity and payer then focuses on prevention. He knows which patients he’ll have to see multiple times in a year because of a chronic condition. Then there are others who may come in with a sore throat that he could see and diagnose quickly.
“It’s all about restricting, rationing, allocating, and looking at solutions,” he said. “I agree that by seeing complex patients you need to be reimbursed more because you spend a lot of time and effort into taking care of older patients. But we’re looking at preventive health right now, we’re looking at isolating highly complex conditions and helping manage them.”
The one last major piece of legislation passed this session: lawmakers decided to transition the controversial Nursing Facility Minimum Payment Amounts Program from one that funnels money to publicly owned nursing facilities to one based on quality incentives. Some of the ways to access that money (none of which is coming from the general fund, mind you) include culture change, small house models, additional staffing, and quality outcome measures. All of which are areas of concern for care of the elderly in Texas.