In December, FHCA Past President Joe Mitchell took part in Governor Ron DeSantes’ Transition Advisory Committee on Health and Wellness. Lt. Governor Jeanette Nuñez and former AHCA Secretary Alan Levine co-chaired the committee, which included more than 50 other health care professionals, regulators and former lawmakers.
The committee was charged with developing and implementing DeSantis’ health care vision, which includes “empowering patients and expanding provider reach, fighting addiction and mental health problems and protecting Florida’s most vulnerable populations while lowering costs and respecting taxpayers’ money,” according to DeSantis transition spokesman Dave Vasquez.
Earlier this week, Joe Mitchell submitted the following letter to Lt. Governor Nuñez and Mr. Levine with recommendations to be included in the final committee report to the Governor. The letter focused on FHCA’s legislative priorities and how they support the Governor’s vision for enhancing Florida’s health care system.
January 10, 2019 Letter to The Honorable Jeanette Nuñez and Alan Levine
Re: Transition Advisory Committee on Health and Wellness
Dear Lt. Governor Nuñez and Mr. Levine:
On behalf of the Board of Directors and members of the Florida Health Care Association (FHCA), I want to thank you for allowing me to serve as a member of the Transition Advisory Committee on Health and Wellness.
Florida Health Care Association is the state’s leading advocacy organization for long term care providers. We represent over 550 care centers which provide skilled nursing, assisted living and other long term care services to over 70,000 frail elders and individuals with disabilities in Florida. By 2020, more than one in five Floridians are expected to be age 65 or older, which means the demand on Florida’s long term care sector will continue to increase. Preserving choice and delivering quality outcomes while being innovative and cost effective will ensure Florida remains a leader in meeting the health care needs of seniors in the years to come.
I was pleased to represent FHCA and Florida’s long term care sector on the Transition Committee and share my insight as a past president of the Association and an owner of 13 quality skilled nursing centers in our state. I’d like to offer the following recommendations to be included in the Committee’s report to Governor DeSantis, given the importance of long term care in the continuum of quality health care services for our state’s citizens.
Keeping Health Care Costs Down and Making Health Care Delivery More Efficient
Liability is a key concern for the long term care profession. Nursing centers are often the target of lawsuits in which plaintiff’s lawyers are focused on recovering the highest amount of money possible in order to maximize the lawyers’ own contingency-fee awards. Since 2014, Florida’s claim severity has increased to over $200,000. The liability costs as a percentage of Florida’s Medicaid reimbursement rate is 8.27% and is the third highest among those states profiled in the AON 2017 Long Term Care General Liability and Professional Liability Actuarial Analysis (Nov. 2017). Florida ranked 46th in the U.S. Chamber’s 2017 State Lawsuit Climate Report which explores how fair and reasonable states’ liability systems are perceived to be by U.S. businesses. Lengthy, costly litigation drives up costs for residents, long term care centers and ultimately, taxpayers.
Proper, well thought-out, and meaningful nursing center litigation reform will help contain costs for Florida’s Medicaid system and ensure nursing centers have the resources needed to provide quality long term health care to Florida’s frailest elders.
Modernize Florida’s Staffing Standards
FHCA is seeking to modernize Florida’s staffing standards to better meet the federal, resident-centered staffing standards. This would allow nursing centers to deliver care in the most effective and efficient methods, using the right staff with the appropriate mix of skills and competencies, to best meet nursing center residents’ needs.
In 2001, Senate Bill 1202 created daily direct care staffing standards, requiring all nursing centers to provide each resident with at least one hour of direct care by nurses who are either an LPN or RN. Certified Nursing Assistant (CNA) direct care was increased to 2.0 hours per patient per day, with incremental increases until reaching 2.9 hours per day in 2010. Because of the cost of the increase on the state Medicaid budget, the Legislature adjusted the standard to 2.6 hours in 2011. The staffing standards have since remained unchanged. Today, Florida centers staff above the vast majority of other states, with an average staffing of 4.3 hours per patient day.
Nursing center residents have a higher acuity level than in 2001, with more than 50% living with Alzheimer’s disease or dementia, receiving rehabilitation, needing mental health services or experiencing mobility problems. More intensive needs require a level of care that calls for physician assistants, ARNPs, therapists and specialists in mental health, respiratory therapy, feeding assistance and other direct care services. Additionally, the federal government now calls for a competency-based approach to care. In 2017, the Centers for Medicare and Medicaid Services mandated that nursing centers use an annual Facility Assessment, which documents each resident’s acuity needs, services provided, medical equipment and facility layout.
Modernizing Florida’s staffing standards to better meet the federal requirements will ensure residents receive the right type of care needed in a setting designed to maintain their health and well-being.
Preserving Nursing Center Certificate of Need
The 2014 Legislature unanimously reformed the nursing center Certificate of Need (CON) process to ensure managed growth where there is a demonstrated need for beds, particularly in rural and underserved areas. The intent was to prevent an oversaturation of nursing centers to keep taxpayers from having to subsidize unused beds.
Without CON, unmanaged growth would lead to lower occupancy rates, which compromises operational efficiency and discourages investment in facility upgrades in technologies and physical plant. Preserving nursing center occupancy rates also delivers cost savings for Florida’s Medicaid program. Each 1% drop in occupancy results in an $11 million increase in the Medicaid line item.
By maintaining the current nursing center Certificate of Need law, Florida seniors now have access to 40 new centers and almost 4,500 new beds. The current system is working to ensure Florida’s long term care sector operates in a high-quality, need-driven environment for Florida’s senior care demands.
Empowering Patients and Expanding Provider Reach
Florida’s Certificate of Need law also ensures the state can maintain its long-standing commitment to help seniors remain in their own home as long as possible. If nursing center certificate of need were to be repealed, more seniors would be moved from home and community-based settings into nursing centers to fill beds. While nursing center care is necessary for the most frail elders, it’s not a necessity for everyone currently living in the less restrictive environment offered by home and community-based care.
Protecting Florida’s Vulnerable Population
Medicaid is the primary payer for long term care. It covers a range of services, including those needed by people to live in the community such as home health and personal care, as well as services provided in traditional settings such as nursing centers. Many of these critical services are not covered by Medicare or private insurance. Medicaid pays for over 60 percent of people receiving nursing center care, and this number is only expected to increase over the next few decades. Skilled nursing centers, however, lose an average of $12.07 per Medicaid patient per day (nearly $297,000 per center annually) due to Medicaid’s chronic underfunding.
There has always been an important link between adequate funding, a stable long term care workforce and high-quality resident care. In 2018, the Florida Legislature increased Medicaid for nursing center care by $138 million, funding an increase in the direct care rate and the quality incentive pool under the Medicaid Prospective Payment System (PPS). FHCA is seeking to renew the Medicaid funding increase for nursing center care in the FY 2019-2020 state budget.
The renewed funding would be used to recruit and retain qualified caregivers and improve staffing and other quality measures.
Once again, I appreciate the opportunity to serve on the Transition Committee and offer these types of solutions that ensure Florida’s nursing center residents receive the best possible services from the best-trained staff, working with modern resources in the most up-to-date centers. If you have any questions, please feel free to contact me.
Joseph D. Mitchell