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Black Cats, Burns and Associates, Cameras, Congressional End Runs and More…

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Black Cats, Burns and Associates, Cameras, Congressional End Runs and More…

by: 
Barbara Merrill, Esq.

Barbara Merrill, Esq.Once upon a time I followed a column dubbed The Black Cat. It ran in a weekly newspaper in Mid-Coast Maine. The author was the editor. It was a hodgepodge — reflections on five or six topics — sometimes provocative, always newsy, frequently funny, rarely related.

I assumed the editor had a cat. Or maybe he saw himself as a jewelry thief-type feline, skulking about in the shadows, observing all, seen by few. Or maybe it was as mundane as he had a cat that made it his mission to interfere with his human’s writing (as mine does when I work on a laptop on my couch at home). Who knows.

The point is I remembered the format, and for this issue of LINKS I am going to adopt The Black Cat’s approach. Let me know if you like it. And yes, I have a black cat. His name, for those of you who don’t follow his adventures on Facebook, is Guy Noir.

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Speaking of shadows, the headlines out of Arizona on the Hacienda case is renewing conversations about permitting cameras to prevent abuse and neglect. ANCOR members, not surprisingly, are all over the place on them — some telling me their attorneys are advising against their use, others adamant they improve services, empowering and protecting individuals served and protecting employees. Obviously, in this tech age, cameras are everywhere — from the videos shot on personal devices to cameras maintained for security at entrances and common areas, to remote monitoring in smart homes. A key ANCOR policy priority is to push CMS and Congress to recognize the importance of assistive technology and supports that enable their use to advance community integration, but it may be just a matter of time before courts conclude they are a standard of care and juries slam providers for not using them to protect people. This promises to be a topic of lively discussion at the "Lessons from Hacienda" Pre-Conference Session at ANCOR's Annual Conference, Bridges to Better Outcomes, this May.

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Burns and Associates. Just the name strikes fear in ANCOR member hearts across the country. (The most commented-on ANCOR Forum discussion EVER was about their work.) But that narrative may be changing in California this week with the release of their long-awaited rate study. It calls for an increase of $1.8 billion for the dramatically underfunded I/DD service system — an aggregate 40% increase to rates. Some codes decreased, but most increased significantly. I’m wading my way through the 103-page report and, while I expect to find DSP wage comparisons with personal care attendants and other similar but low-paid occupations, I hope our discussions with Steven Palauski from Burns and Associates impressed upon him the necessity of determining what wages must be to significantly reduce DSP turnover rates. I’m waiting to get feedback from our California members and will keep you posted.

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Paying for performance and nursing homes have been top of mind this month. Good reason — the Senate Finance Committee held a hearing on quality issues, the New York Times ran an article about rural facilities closing across the country, and I saw a big ad at Washington National Airport that announced advances in nursing facility quality. (Smart move, advertising in the airport that almost every member of Congress uses twice a week. Note to self: find out what ads cost there). 

What most caught my attention in the NYT article and in stories linked from it were two issues: the impact of their workforce shortage and the Medicare Value-Based Purchasing Program incentives. (Note: the Times article listed multiple reasons for the rural closures, including poor reimbursement rates, seniors choosing assisted living and home care and persistent quality problems). But I zeroed in on the VBP impact. Of course I did; it’s all the rage (and yet, as we will be discussing at our Annual Conference, so far in our space, there’s little there, there; that could and likely will change).

The nursing home VBP experience is important for us to reflect on. Passed in 2014, Medicare now assigns penalties and bonuses on each facility's hospitalization rate as compared to other facilities, and how much those rates changed from 2015. So, how has it worked out? Kaiser Health News reported in December 2018 that Medicare lowered a year’s worth of payments to nearly 11,000 nursing homes — and gave bonuses to only 4,000 others.

That’s the definition of a double whammy. You can’t recruit and retain enough direct care staff (or RNs for that matter), and then you get hit for excessive readmission rates to hospitals.

This is a cautionary tale for us.

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Work requirements for the “able-bodied” Medicaid expansion population continue to make health news. Ohio’s proposal was just approved by CMS, prompting me to ask Sarah Meek, ANCOR’s Director of Legislative Affairs, for clarification on exactly what "able bodied" means. She pointed me to a very informative 2018 article that provides a historical overview of what the term means, and to whom. I highly recommend the article to you — particularly if you are a student of history. I’ll be candid: like ANCOR Past President Angela King shared in her 2017 speech in San Antonio, I find the effort to determine who is and isn’t the “deserving poor” problematic. Sarah commented that although states are seeking to exempt the disability population from work requirements, there is anecdotal evidence that people with intellectual disabilities, often on state waiting lists for LTSS, have come onto the Medicaid rolls through expansion.

We’re not just watching work requirements. Regular readers of Capital Correspondence know that the President’s budget includes cuts to Medicaid, including a reprise of the Medicaid block grant/per-capita cap proposal defeated in 2017. Given the divided Congress, the budget as proposed will not become law. But the Trump Administration’s health policy agenda, led by Secretary Azar and CMS Administrator Seema Verma, is actively seeking to advance as much as it possibly can through executive/administrative action, including outreach from CMS to red states to encourage block grant/per-capita cap programs. This is setting up for a big fight — for more insight, I recommend this article from The Hill.

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ANCOR members tell us they look to us to help them stay ahead of the curve — to understand coming trends, regulatory developments, and promising and best practices. We work hard to ensure our conference includes content that gets people out of their comfort zone. Keynoter Poppy Crum will check that box this year — I expect to find her talk on artificial intelligence both inspirational and unnerving. Maybe even a bit creepy…

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So, like the format? Comments about these musings? Send me an email at bmerrill@ancor.org. I’d love to hear from you. By the way, Guy Noir lives on the 12th Floor of the Acme building. And he’s quite the lover of poetry. Maybe someday you’ll be able to follow him on Instagram — or adopt him.

Barbara Merrill is CEO of ANCOR.