Washington must pay existing Medicaid costs before requiring new ones in state

Anyone who ever had a loved one in a nursing home won’t deny the appeal of there being more caregiving staff to serve patients.

With the best of intentions, some advocates are pushing to require caregiving staffing ratios for Washington’s nursing homes. Examples are given of other states requiring this, such as Oregon.

Left unsaid, however, is that other states pay for their expectations. Oregon, for example, values its nursing home patients with a Medicaid rate over $60 more per day than Washington’s, despite Washington being second only to Maine in the medical need of its nursing home patients.

Further, the new push for staffing minimums would layer another requirement atop a system that ignores existing care costs. Through June 30 of this year, Medicaid “reimbursement” is based upon 2007 costs. Gov. Jay Inslee proposed updating payments to 2013 costs, but his proposal did little to address this state’s $100 million yearly shortfall in nursing home reimbursement rates.

Were a staffing requirement implemented here, it might, unlike systems in Oregon and elsewhere, compound the damage done by a system that allows Washington to selectively choose it wants to pay for care of state patients. Thus, nursing homes might be forced to hire and pay for additional certified nursing assistants; but other support staff, such as housekeeping and kitchen staff, would be ignored, even though their work is an integral part of care that brings them into daily contact with patients. In addition, the 2015 Affordable Care Act health insurance costs of all staff, including any required new hires, would continue to be ignored by the state.

It’s also too reductive to believe caregiver staffing alone brings quality. Mathematical formulas are not enough; good management is key.

Indeed, nursing home inspection findings can seem counterintuitive. With more private-paying patients, nonprofit nursing homes have traditionally been able to afford more staff. Yet, according to the Center for Medicare and Medicaid Services’ 2013 “Nursing Home Data Compendium,” 8 percent of for-profit facility surveys resulted in zero health deficiency citations, as compared to 5 percent of nonprofit surveys. Similarly, citation for “immediate jeopardy” was only half as likely in a for-profit facility (1.3 percent) as in a nonprofit (2.5 percent), while a citation for substandard quality of care was only a quarter as likely (.6 percent vs. 2.5 percent).

One cannot infer from these findings that any care setting type is superior to another; the only lesson is that often-arbitrary measurements of quality can defy your expectations. Perhaps the real story of survey results in Washington is how facilities of all ownership types have excelled despite Medicaid underfunding and patient need that exceeds 48 other states. In Washington, citations for substandard quality of care fell 67.1 percent from 2008-2012 (Oregon’s fell 45 percent). Workers’ compensation rates have declined too, as facilities have invested in “zero-lift” equipment and other ergonomic improvements.

For too long, Washington’s nursing homes have done more with less.

The state must pay existing Medicaid costs before requiring new ones.