Two bills that would require nursing homes to devote 80% of their funds to the direct care of residents moved through the Human Services Committee on Thursday despite objections from industry leaders, advocates and a key state official.
One proposal would require facilities to spend 80% of all revenue on direct care, including Medicaid, Medicare and private money. A second, which is part of a larger health care reform bill, mandates that nursing homes set aside 80% of public funds — Medicare and Medicaid — to direct care.
Connecticut nursing homes currently spend 51%.
Direct care is defined as the hands-on care provided to residents by nurses or nurse aides, including feeding, bathing, dressing and medication administration.
Republicans on the Human Services Committee raised concerns about limiting how the facilities spend money.
The measures could hamper building renovations, food delivery services and other needed resources, they argued.
“These homes are aging, and if we do something like this, it’s just going to restrict and put projects on the back burner,” said Rep. Jay Case, R-Winchester, a ranking Republican on the committee. “These facilities take care of our most vulnerable people — our elderly, our veterans, our special needs [residents] — and to restrict how a business does this — I think there are other ways.
“We’re really tying their hands. And you might see some [companies] that may not want to be here.”
“Under a Certificate of Need process in a nursing home, someone might say, ‘Yeah, that’s great, 80% [is spent on direct care], but we also want to measure you on your cleanliness, food preparation, safety protocols and all that,’” added Rep. William Pizzuto, R-Middlebury. “If 20% isn’t enough, what do they do? What suffers? I mean, they won’t meet this need.”
Industry executives, advocates and the head of Connecticut’s social services department also raised concerns.
Mairead Painter, the state’s long-term care ombudsman, said the state recently narrowed its definition of “direct care” in nursing homes to include only nurses and nursing aides.
“We in Connecticut last year redefined direct care and made it very, very narrow in scope to only be nurses and certified nursing aides on the floor. People providing activities of daily living on the unit are the only people who can be counted toward direct care,” she said. “If you put 80% of our funding into that … you won’t be able to have social workers, recreation, dietary, maintenance, and housekeeping.
“Although well intended, it would create significant gaps in other ways.”
Painter said that by keeping the definition of direct care narrow, however, it should be easier to measure how much funding is being committed to nursing services versus other types of expenses and shape policy based on that.
Leaders in the nursing home sector also expressed fears about covering costs outside of nursing care. Professional fees, laundry services, maintenance, property taxes, rent and myriad other expenses could suffer, they noted.
“We are opposed to this provision because [other] cost components used in setting nursing home rates are essential and mandating 80% of Medicaid funding be spent on direct care would unsatisfactorily leave only 20% of the overall Medicaid funding for all other nursing homes services and supports,” Matthew Barrett, president and CEO of the Connecticut Association of Health Care Facilities, wrote to lawmakers.
“While we highly value the work of nurses and nursing aides, the way this bill is crafted, it is unworkable,” added Mag Morelli, president of LeadingAge Connecticut, which represents nonprofit nursing homes and other providers. “We recognize the concerns that led to this proposal; however, it will lead to unintended operational challenges which do not acknowledge the realities of nursing home care and services.”
Andrea Barton Reeves, the state’s commissioner of social services, also opposed the spending mandate, saying it would have “adverse consequences” that include undercutting the state’s new acuity-based reimbursement system for nursing homes.
Some lawmakers and advocates backed the bills.
“These requirements are somewhat similar to the federal medical loss ratio requirements on health insurers that require 80% of premium dollars for small group plans be spent on medical care and a maximum of 20% can be spent on administrative costs,” Senate President Pro Tem Martin Looney, D-New Haven, testified. “I would support including additional transparency requirements on nursing home facilities so the state and our residents can see how nursing homes spend their revenue and how they prioritize patient care.”
Officials with AARP Connecticut wrote in testimony to legislators: “Spending on patient care is essential to ensuring that our most vulnerable seniors get the basic care they deserve. There is a direct connection between spending on direct care nursing and nurse aide staff and the quality of care that residents receive.”
Similar proposals have been considered in the legislature’s Aging Committee in recent years but have not advanced.