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Report: Medicaid Falls Short on Costs of Care in Nursing Homes<p><img src="/Articles/PublishingImages/740%20x%20740/0120_News1.jpg" class="ms-rtePosition-1" alt="" style="margin&#58;5px;width&#58;200px;height&#58;200px;" /></p><p>The Medicaid and CHIP Payment and Access Commission (MACPAC) <a href="https&#58;//" target="_blank">recently issue a brief</a> on Medicaid nursing home payments relative to the costs for care. The brief, which was highlighted last week at MACPAC's first public meeting of 2023, found Medicaid does not actually offset what it costs to care for residents. Based off payments from 2019, MACPAC found “the median Medicaid base payment rate in 2019 was 86 percent of reported facility costs.&quot;</p><p>But much has changed for nursing homes since 2019, as nursing home costs have skyrocketed over the last three years due to the COVID-19 pandemic. The personal protective equipment (PPE), testing, and staff needed to combat a multi-year public health crisis has cost nursing homes billions of dollars. In 2020 alone, <a href="https&#58;//" target="_blank">nursing homes spent $30 billion</a> on PPE and labor.</p><p>Labor costs are also increasing. As staffing shortages persist, a recent survey from the <a href="https&#58;//" target="_blank">American Health Care Association (AHCA) found</a> that more than nine out of 10 nursing home providers have increased wages and offered bonuses to try and recruit and retain staff. Nearly 80 percent have turned to staffing agencies to adjust for shortages, which are often costly.</p><p>As costs continue to increase and inflation soars, Medicaid reimbursement rates are not keeping up. The same survey showed more than half of nursing homes are operating at a loss.</p><p>Another upcoming study, conducted by CliftonLarsonAllen LLP (CLA), highlights significant risks to nursing homes, including current and projected negative operating margins, the increasing cost of care, chronic issues such as underfunding and the workforce crisis, occupancy loss, and the threat of facility closures. <a href="https&#58;//" target="_blank">Hundreds of thousands of residents</a> are currently located in nursing homes that could be financially “at risk of closure.&quot;</p><p>The data in the MACPAC brief does not debate this underfunding. One table in the brief shows a breakdown on total facility costs per day along with Medicaid-covered costs. The average total costs per day per resident for all facilities is $293.36 per day, compared to the $243.61 for Medicaid-covered costs.</p><p>“We've been sounding the alarm on low Medicaid reimbursement rates for years,&quot; said Mark Parkinson, president and CEO of the American Health Care Association and National Center for Assisted Living (AHCA/NCAL). “The majority of our nursing homes rely on Medicaid, but the system is flawed. We really need lawmakers to prioritize this issue and make significant investments to better support our nation's seniors and caregivers.&quot;</p><p>The brief also noted, “costs have historically been used to assess Medicaid nursing facility payments, but they are an imperfect measure of what facilities should be paid.&quot;</p><p>“The MACPAC brief notes the inconsistency in data for costs, which are ultimately used to determine Medicaid reimbursement rates for facilities,&quot; said AHCA/NCAL's senior vice president of quality, regulatory and clinical services Holly Harmon, RN. “Nursing homes are struggling to stay afloat because of inadequate funding. Without immediate action from Congress, these shortfalls could lead to more closures and leave our most vulnerable without the care they need.&quot;</p><img src="/Articles/PublishingImages/2023/AbbyBarreto.jpg" alt="Abby Barreto" class="ms-rtePosition-2" style="margin&#58;5px;width&#58;146px;height&#58;184px;" /><p>MACPAC also added that “because nursing facilities serve a wide range of residents with different care needs, the costs of care for each resident is not the same.&quot; Sarah Schumann, vice president of operations at Brookside Inn in Colorado, strongly agrees.</p><p>“Each one of our residents is unique,&quot; said Schumann. “We provide specialized, one-on-one care to everyone who walks through our doors, and we need Medicaid reimbursements that fully cover the cost of care. We hope policymakers hear our calls for help and make improvements.&quot;</p><p><em>Editor's note&#58; Children's Health Insurance Program (CHIP)</em></p><p><em>Abigail Barreto is senior director of public affairs at AHCA/NCAL.</em></p><p>​</p>2023-02-02T05:00:00Z<img alt="" src="/Articles/PublishingImages/740%20x%20740/0120_News1.jpg" style="BORDER&#58;0px solid;" />MedicareAbigail BarretoMACPAC recently issue a brief on Medicaid nursing home payments relative to the costs for care. The brief found Medicaid does not actually offset what it costs to care for residents.
Increased Use of Telemedicine Brings Numerous Benefits for SNFs<p><strong class="ms-rteForeColor-2" style="">ADVERTORIAL</strong></p><p><img src="/Articles/PublishingImages/2023/Kevin-Carpenter.jpg" alt="Kevin Carpenter, MD" class="ms-rtePosition-2" style="margin&#58;5px;width&#58;200px;height&#58;200px;" />As we move forward in 2023, it’s uplifting to see census returning to near pre-pandemic levels for many providers. Unfortunately, many of these same facilities are still experiencing staffing challenges and the daunting reality of higher-acuity residents. With over 50 percent of U.S. hospitals operating in the red, the trend to discharge patients from the acute setting faster and sicker will surely continue. </p><h3>An increase in acuity requires more physician access.</h3><p>Skilled nursing facilities (SNFs) are increasingly shouldering the responsibility of complex hospital discharges, which test staff capabilities and negatively affect quality scores. Some providers have welcomed a higher-acuity strategy as an opportunity to build census, but physician access for these patients remains limited. Newly admitted patients may not see a physician for an assessment on the first day, and long-term care residents may only see a physician once a month. Physician access differs vastly from the acute-care setting, where doctors can be at the bedside 24/7 when needed. <br></p><h3>Telemedicine is the only cost-effective means to increase access to physician services.</h3><p>If the pandemic had a silver lining, it was telemedicine. The U.S. Department of Health and Human Services reported a 63-fold increase in Medicare telehealth utilization in 2020. Better technology, the need for infection control, and regulatory changes in the Coronavirus Aid, Relief, and Economic Security (CARES) Act expanded the opportunity to positively impact SNF outcomes. When deployed correctly, telemedicine is the most effective and affordable way to place a physician at the bedside 24 hours a day. Video-enabled virtual care provides the means to assess, manage, and treat changes in condition, in partnership with an attending nurse. It’s especially effective for nights and weekends. <br></p><h3>Today it’s about more, not less.</h3><p>Despite its promising potential, SNF telemedicine was initially met with a hefty dose of skepticism. Medical directors and attending physicians feared their billable encounters—or even their jobs—could be at risk. Nurses worried physicians would spend less time in the building. Providers worried about liability. And families assumed that telemedicine would replace in-person care for their loved ones.</p><p>Fortunately for long term and post-acute care residents, attitudes have shifted dramatically over the past few years. Today, there is broad and growing acknowledgment of telemedicine’s value and data to prove clinical efficacy and improved outcomes.<br></p><h3>Telemedicine assists in managing transfers to and from acute settings.</h3><p>One of the biggest challenges happens when residents need hospital-level services. Transfers at night create the most risk because understaffed emergency departments (EDs) don’t always prioritize SNF residents for treatment. We’ve seen a dramatic difference when an ED transfer workflow includes a tele-physician consult followed by direct communication from the tele-physician to the ED. When an engaged physician speaks directly to an ED physician to advocate on the patient’s behalf, the scenario for the patient changes. Telemedicine makes this possible, even overnight. The result is faster care, appropriate utilization, and less time in the hospital. We manage hundreds of ED transfers each month, and 39 percent of residents return to the SNF without hospital readmission. </p><p>Likewise, when patients arrive or return to the SNF, seeing a physician within a few hours can significantly improve the transition of care. Patients and families have shared how comforting it is to see a physician and have questions answered on day one. A video encounter can address medications, pain management, and a care plan to set the patient up for success until they can be seen in person by a physician. </p><h3>Integration makes a difference.</h3><p>SNF telemedicine is a two-way conversation initiated by a nurse at the bedside. Nurses use telemedicine more often when the process is easy, integrated into their existing workflow, and intuitive. Our partnership with PointClickCare makes telemedicine accessible directly in the patient chart, and utilization has skyrocketed. One regional organization saw a remarkable 300 percent increase in consultations—94 percent of which resulted in residents receiving treatment without having to leave their facility. </p><h3>Telemedicine has a positive impact on SNF operations.</h3><p>For SNFs, the return on investment from telemedicine shows up in myriad ways. Revenue is saved by reducing hospital readmissions and lost bed days. Administrative costs go down with uninterrupted care and fewer expenses tied to hospital transfers. Additional value accrues with improved quality scores, better hospital relationships, and more referrals through high-quality SNF networks. Additionally, numerous organizations see increased nursing satisfaction from this additional level of responsive support, even using their program to help recruit nurses. <br><br>Find out more about how Sound Physicians supports SNFs with telemedicine services. Visit <a href="http&#58;//" target="_blank"></a>.<em><br></em></p><p><em>Brian Carpenter, MD, SFHM, is chief medical officer, telemedicine, for Sound Physicians.</em><br></p>2023-01-31T05:00:00Z<img alt="" src="/Articles/PublishingImages/2023/Kevin-Carpenter.jpg" style="BORDER&#58;0px solid;" />TelemedicineBrian Carpenter, MDWhen deployed correctly, telemedicine is the most effective and affordable way to place a physician at the bedside 24 hours a day.
3 Strategies to Prioritize Accounts Receivable Management<p><img src="/Articles/PublishingImages/740%20x%20740/healthcare_finance.jpg" class="ms-rtePosition-2" alt="" style="margin&#58;5px;width&#58;200px;height&#58;200px;" />​2022 was another big year of regulatory change and financial hurdles for the long term care industry. Long term care operators saw phased Patient Driven Payment Model (PDPM) cuts, the growth of managed care takebacks, and a major draft release of the Minimum Data Set (MDS) 3.0. That is a lot to digest, and this much change means even more research, training, and operational enhancements to make sure communities are accurately reimbursed for the care they provide.</p><p>However, there’s another financial threat that communities should be focusing on in 2023&#58; aging accounts receivable (A/R).</p><p>Facilities across the country are sitting on millions of dollars in unpaid claims due to COVID-19 ripple effects, back-office staffing problems, and increased payor complexity. Operating costs are still up, and the census is still down, putting even more of a financial strain on the facility. Staffing struggles persist, despite raising salaries during the Great Resignation. The costs of clinical supplies, utilities, and resident meals are not decreasing even as inflation plateaus.</p><p>Accounts receivable should not be treated as the drop-off point in the revenue cycle, or the project to be worked on when you have 10 minutes to spare. A facility’s aging A/R is money earned through quality care; it is due to the facility, and it needs to be collected. </p><h3>Professionalize Your Facility’s A/R Management </h3><p>After working in the long term care industry for over 40 years and serving in various positions, such as business office manager, administrative roles, and consultant to the facility owner, here are three strategies I recommend to administrators. These strategies are relevant whether you have a centralized billing office or a one- to two-person team covering the whole back office.</p><h4>1. Review the aging report monthly, at a minimum. </h4><p>Billers should be reviewing the aging report daily. Administrators should review it once a month, at a minimum, to identify trends, determine process improvement priorities, and monitor performance. When reviewing the aging, focus on three key performance indicators&#58; net collections, days sales outstanding, and A/R over 90 days. These metrics define A/R health, help to identify how much and how quickly money was collected, and what amount is at risk of not being collected. <br></p><h4>2. Prioritize claims and make sure the team has dedicated time to work on the A/R. </h4><p>Once the aging has been reviewed, prioritize the workload. There is only so much time in the day and working a single claim can take anywhere from five minutes to two hours or more. The objective is to collect as much money as efficiently as possible; strategizing and working claims systematically will assist with this process.</p><p>Start with claims aged at the timely filing limit to ensure minimal write offs. Secondly, prioritize new aging in the 30-, 60-, and 90-day columns. Lastly, prioritize based on business needs and trends. Remember, there are no unimportant claims; keep in mind how collections can be maximized for staff time and dollars spent. Prioritize the highest dollar claims, or a particular payer that is known to pay slowly. <br></p><h4>3. Champion fixing processes, not just correcting claims. </h4><p>Overstretched teams tend to focus on the immediate billing crisis, not the root cause. Like treating a patient’s symptoms without diagnosing the illness may result in temporary relief, the same problem will keep coming back. As a leader, start asking your team tougher questions during the monthly A/R reviews. What payers have the highest balances? Why? If unknown, what needs to be researched to find out? What is the root cause? Are the payers set up correctly in the A/R system? When was this last checked? Are claims escalated appropriately?</p><p>Consider an A/R assessment from an outside source. These assessments identify aging issues and provide recommendations for communities. Unsurprisingly, if a facility does not have the time or take the time to correct their upstream processes, the frustration will continue with no meaningful progress on the A/R and continued claim denials. <br></p><h3>Collect More with Help </h3><p>Another strategy to get back on track is to outsource your revenue cycle management (RCM) or to bring in a partner for an A/R clean-up. With the right partner, outsourcing RCM can increase collections up to 98 percent. An A/R clean-up will help you catch up on your aging while relieving your team to focus on current billing and broader process improvements. </p><p>The thought of hiring external experts for financial help may seem threatening to the team. They may feel someone is there to criticize and point out all the things they are doing wrong. But, reassuring and supplementing the team with an expert partner will assist with cash flow and getting claims paid, unlock staff time for other priorities, and stabilize the back office. </p><p><img src="/Articles/PublishingImages/2023/Kristy-Brown.jpg" alt="Kristy Brown" class="ms-rtePosition-2" style="margin&#58;5px;width&#58;200px;height&#58;200px;" />“Doing more with less” is a badge of honor in long term care, but our job as leaders is to put a strategy in place that will make our facilities and teams successful.</p><p>Creativity and a sense of partnership will help pave the way for the challenging financial times ahead. Take a closer look at your A/R processes and see what low-hanging-fruit improvements you can make. <br>&#160;<br><em>Kristy Brown is the director of skilled nursing facility financial services at Quality Healthcare Resources, an Assembly Health company. She has over 40 years of experience in the long term care industry and was recently recognized with a McKnight’s Long Term Care News Pinnacle Award.<br></em></p><p><em><br></em></p><p style="text-align&#58;center;"><strong class="ms-rteForeColor-2" style="">Learn more&#58;</strong></p><p style="text-align&#58;center;"><em><a href="https&#58;//"><img src="/Articles/PublishingImages/2023/RCM%20Academy_promo.png" alt="" style="margin&#58;5px;" /></a><br></em></p>2023-01-31T05:00:00Z<img alt="" src="/Articles/PublishingImages/2023/Kristy-Brown.jpg" style="BORDER&#58;0px solid;" />FinanceKristy BrownA facility’s aging A/R is money earned through quality care; it is due to the facility, and it needs to be collected.
Nonprofit Organizations Help Grow the Long Term Care Workforce<p><img src="/PublishingImages/Headshots/PaulBergeron.jpg" alt="Paul Bergeron" class="ms-rtePosition-2" style="margin&#58;5px;width&#58;200px;height&#58;200px;" />​Nonprofit groups are stepping up their efforts to grow the nursing and long term care workforce through creative and uplifting programs that give candidates full-time jobs both during training and upon graduation.</p><p>The Jack and Nancy Dwyer Workforce Development Center, a 501(c)(3) nonprofit, works with other not-for-profits, partner workforce development organizations, and training partners to develop workers. Its students, called Dwyer Scholars, complete their training, participate in clinicals, and then take the Board of Nursing exam.</p><p>The program’s goal is to “help those who lack opportunity and aspire to pursue a career in the healthcare industry by removing barriers that prevent them from success,” Dwyer Workforce Development CEO Barb Clapp said. “Our mission is also to alleviate a severe healthcare workforce shortage and improve the lives of seniors.”</p><p>Dwyer Workforce Development’s goal is to help those who lack opportunity and remove barriers that prevent them from success by providing free certified nursing assistant (CNA) job training. Once certified, DWD places Dwyer Scholars into full-time positions through its network of long term care industry partners. In 2022 DWD, based in Baltimore, trained 286 scholars in Maryland; the program has a 95 percent stick rate.</p><p>DWD recently executed a $590 million acquisition of a Texas-based skilled-nursing-facility portfolio managed by Regency Integrated Health Services. With the acquisition, it transitioned the portfolio from a for-profit to a not-for-profit organization, which was the vision of entrepreneur Jack Dwyer to end systemic poverty and address the growing workforce crisis plaguing the health care industry.</p><p>“He wanted to fund the Texas program in perpetuity,” Clapp said. In Texas, DWD will train an additional 414 scholars and employs about 6,750.</p><h3>Set Up for Success on Day One</h3><p>As part of the training process, Dwyer Scholars are paired with case managers who work closely with them to identify career ladder goals to achieve over several years—keeping them on track for success. On a need basis, Dwyer Scholars are provided with wrap-around services, which include financial support for housing, childcare, transportation, and more, ensuring students are set up to succeed from day one.</p><p>“Our scholars could be single paycheck mothers, young people who have had enrichment programs in city schools but can’t afford pursuing a health care career in college, from foster homes, formerly in addictive treatments or recovering from domestic violence programs,” Clapp said. “If their child is sick and can’t go to school, they have no one to care for them. The case management support that we offer them makes the difference.”</p><p>In one case, a scholar had her child in daycare, but the daily training time period conflicted with the daycare schedule, so the case manager was able to get the scholar into training hours that fit her schedule.</p><p>“These are the types of conflicts that can happen to any adult who is just trying to get ahead,” Clapp said. DWD also uses an app as an incentive tool that rewards participants for active participation in the Dwyer Scholar program. </p><p>“They are encouraged to check in daily to let their case manager know how they are doing,” Clapp said. The scholar is rewarded for staying in the program at 3-, 6-, 9-month, and one-year intervals. “They get points and can cash the points in for gift cards and other needed items such as scrubs or work shoes.”</p><h3>MaineGeneral Offers Work While Students Train</h3><p>MaineGeneral Health has been operating its CNA Earn to Learn training program since 2018, offering four classes per year. More than 200 students have graduated from the program. By finding more trainers, in 2022, the number of classes MaineGeneral conducted doubled from four to eight.</p><p>To drive participation, MaineGeneral recruiters attend job fairs to engage with the community one-on-one. Recruiters also visit students at local schools, use social media platforms, engage local radio stations, and post on job sites. The program also recruits internally from non-clinical entry-level positions throughout its health system.</p><p>There are other CNA training programs in the state of Maine but Tarsha Rodrigue, Administrative Director at MaineGeneral Rehabilitation and Long Term Care, said Earn to Learn differentiates itself from the others because it hires its students into full-time positions.</p><p>Students’ time in class is supplemented with paid work hours serving in its skilled rehabilitation and long term care facilities. When not in clinical and class, the students are working as helpers in the facility, engaging with residents, participating in activities, and stocking and tidying rooms.</p><p>“This program has significantly helped in recruiting into the CNA role and beyond,” Rodrigue said. “We have graduates from this program who have continued to grow professionally and work in other areas of the organization.” Some are now medical assistants, CNA-medication technicians, phlebotomists, and registered nurses. <br></p><p>“Prior to the pandemic, this program assisted our long-term care facilities in eliminating agency and temporary labor,” Rodriguez said. “I am very proud of our CNA training program. We expect it to continue the success it has seen so far. This course is about so much more than meeting our staffing needs.”</p><h3>More Than Staffing, An Opportunity</h3><p>MaineGeneral holds a ceremony after each class graduates. There, at least one student shares with the group inspiring stories about how the class has given them a new opportunity, fulfilled a dream, or gave them a new purpose.</p><p>Aubrey Trout, a December 2022 graduate, got a late start on her career. “I decided that I would very much like to become a nurse, and at going on 40 years old, I should probably get a move on,” Trout said.</p><p>“However, at that point in time I would not have been able to afford paying for a CNA course, let alone nursing school. As I was searching for options that I could realistically consider, the MaineGeneral opportunity presented itself to me, so I seized it. I am now a CNA with intentions of becoming a registered nurse, and I feel like I have found the path I was looking for.” </p><p>She said the residents and the relationships she has developed with them over time makes it a rewarding career. “There is something profound and beautiful about having the trust of someone to do for them the things they cannot do for themselves,” Trout said. “I feel quite privileged to be in a position to provide that kind of care, and in a way that makes what is often times the remainder of someone’s life as comfortable and as meaningful as possible.”</p>2023-01-24T05:00:00Z<img alt="" src="/Articles/PublishingImages/740%20x%20740/0220_News2.jpg" style="BORDER&#58;0px solid;" />ManagementPaul BergeronNonprofit groups are stepping up their efforts to grow the nursing and long term care workforce through creative and uplifting programs that give candidates full-time jobs both during training and upon graduation.


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