Centers for Medicare and Medicaid Services

have to reply to four of my peers discussions 200 words

Based on, Medicaid Assisted Living Services: Improved Federal Oversight of Beneficiary Health and Welfare Is Needed, answer the following questions:

  1. Why was the study conducted?
  2. What are the identified problems in the provision of assisted living services?
  3. Do you agree with the conclusions and recommendations of the study? (remember to explain why/why not). How will this affect providers? How will this affect consumers

The study was conducted at the request of CMS to examine the government oversite of the assisted living services in Medicaid. As the federal government contributes money to the Medicaid programs they were investigating those states that cover assisted living services under Medicaid.  The Centers for Medicare and Medicaid Services wanted to “ensure that their beneficiaries’ health and welfare is protected.” (GAO-18-179, 2018) Assisted living is not generally covered under the Medicaid program but many states allow coverage through various waivers but there is no federal oversite of that practice. The largest problem identified in the study is the lack of standardized oversite.  Each state is responsible for the overall management of the Medicaid program and oversite of its services.  There is no federal standard regarding oversite assisted living services or even general guidance on how to manage assisted living services.  This has created problems with reporting, services offered, eligibility, inspections and sanctions.  With no standard to track their beneficiaries states are essentially left to make their own rules on how assisted living is provided. For CMS to ensure the safety of their beneficiaries there should be more involved with the assisted living programs that they cover.

I do agree that there needs to be better federal oversite of the Medicaid eligible assisted living facilities. It is not possible to know what is happening to all the people utilizing assisted living if there is no standard with regards to basic services, eligibility and reporting. Implementing any standardization would be beneficial to consumers as they would have confidence that their facility would be meeting a standard that best cares for them.  Providers would need to meet the standard set regarding quality of care, services and reporting of incidents. More can definitely be done as CMS has only adopted a standardization with regards to the application process and has only given vague guidance to states for reporting and services.

US Government Accountability Office. (2018) GAO Report to Congressional Requesters:  Medicaid Assisted Living Services

example of what someone responded

Hi Regina,

I agree that mentioning how  important it is for Medicaid to take reporting and monitoring incidents in the study is one of the best recommendations. It is known that lot of incidents have “fell through the cracks” due to the lack of monitoring on the states side and how lenient the regulations is toward facilities. That needs to be revised because a lot of unknown deaths of patients has not been investigated or brought to light and this can cause even more issues for facilities in the future and the reputation of how they treat patients. Another recommendation that I read in the article is that medicaid is now allowing assisted living services for elderly as well as disabled,  working for disabled people I have noticed a lot of them need more services than are provided in a group home setting.

Why was the study conducted?

The U.S. Governmental Accountability Office (GAO) study of all state Medicaid agencies was conducted due to the increase of older people and people with disabilities receiving long-term care services.  GAO sought to better understand the state and federal spending and oversight of care at assisted living facilities. (GAO, 2018).

What are the identified problems in the provision of assisted living services?

The major problem identified in the provision of assisted living services was that 26 of the 48 Medicaid agencies lacked reporting of critical incidents, such as abuse, neglect, and exploitation, in assisted living facilities.  Furthermore, all states had varying definitions of what was considered a critical incident.  Reporting of critical incidents was also not available to the public in 14 states. (GAO, 2018).

Do you agree with the conclusions and recommendations of the study? (remember to explain why/why not).

The CMS made three recommendations that the Administrator: (1) provide guidance and clarify the requirement for monitoring and reporting deficiencies, (2) establish standard Medicare reporting requirements for critical incidents, and (3) ensure all states submit annual reports on time. (GAO, 2018).

I strongly agree with the above recommendations to improve reporting incidents of abuse, neglect, and exploitation.  Unfortunately, due to the pandemic, the implementation of these recommendations will likely be delayed. In the interim, GAO should conduct a new study to investigate the oversight of care at nursing homes and assisted living facilities during the pandemic.  Additional problems may be identified that will result in new laws and reporting requirements not previously considered.

How will this affect providers?

The recommendations primarily affect state Medicaid offices. However, since 26 states do not report critical incidents, providers operating in those states may be affected by the new reporting requirements.  Training and new hires might be necessary to meet compliance requirements and will also increase the provider’s administrative costs.

How will this affect consumers?

Overall, consumers will be affected positively since the recommendations protect assisted living residents.  Furthermore, by standardizing reporting and publishing deficiencies, consumers will be able to make better-informed decisions about choosing a provider for their care.

example of what someone wrote

Hi Catherine,

I also did agree with the recommendations that the study mentioned. I agreed with the expansion of taking reporting, and neglect more seriously and to be fully investigated by the state. Another thing that was mentioned  that I agreed with is that they said two sections of medicaid that will provide assisted living services such as the elderly and people with disability. As someone who worked with people with disabilities I think it will be beneficial for these services to be accessible to them as well. I could imagine that the pandemic will make regulations change for the best because the insurance companies and LTC facilities will see more than ever where the regulations weren’t as strong as they will they were at a time of need.

second discussion

Competition arises within long-term care providers because they are trying to provide the best service in a more cost efficient way in order to attract individuals searching for care. In the past, long term care was not subject to strong competition because of the monopoly of the services they offered and the demand for payments was not present. However, lately there have been new market entities who have increased marketing. Competition from home health agencies similarly has mixed effects on nursing home care quality, and competition from other nursing homes in a market tends to decrease quality of care (Chies, 2020).  The use of data for strategic positioning purposes is readily available these days.  The government has also forced restrictions on both payments, and services provided. Information about price and quality greatly increased competition. Medicaid and Medicare payments were obtainable but the quality of a facility was not. Now this information is available and leads to an increase in competitive advantage, home health agencies can use this info to make changes to their processes and services in order to become more successful over others.

In the future we will see the benefits of competition in integrated long-term care. These benefits are improved management, better coordinated care, quality of care, and measuring clinical outcome. Utilizing quality care information as a competitive tool will aid in strategic planning to improve their own facilities (Chies, 2020). This will benefit the residents and improve their quality of life. It also should ensure more obtainable pricing. The competitive nature of the business could lead the facilities to remain up to date on accreditations, increased safety and quality of care. I feel that introducing a competition this enables any health care operation to expect more out of their organization and thrive to improve within all aspects of their spectrum of care.

Chies, S. (2020). Pratt’s long-term care. Managing across a continuum: (5th ed.) Jones & Bartlett

Example of someone reply

Hi Samantha,

I agree that in the future of long term care their will be a lot of competition in the upcoming years,especially due to the hospital realizing the profit they can receive by providing services in-home. With this, comes certain regulations that hospitals can do meanwhile home health agencies have certain stipulations like doing an excessive amount of paperwork. An example that the textbook gave Chies(2021)was that hospitals and private physician offices are partnering up to provide acute care and ambulatory services due to wanting to shorten the reduction of health care costs which is a great tactic!I hope in the future whichever path grows it will ensure the best quality care for the patients, them being vulnerable deserve the upmost person centered care.

In Chapter 9 of the textbook, “Pratt’s Long-Term Care”, by Steven Chies, the five conditions required for effective competition on long-term care include that: (1) no individual buyers or sellers have any significant influence on the market price, (2) no collusion occurs among the buyers or sellers to fix the market price, (3) new buyers and sellers can easily enter the market, (4) there are no government restrictions, and (5) good information is widely available about the market price and quantity (access). (Chies, 2021).

Before the 1990s, there was no competition. The federal and state governments financed most of the long-term care through Medicaid and Medicare. Private insurance companies generally did not offer coverage for long-term care.  In recent decades, managed care has become a major competitor through Medicaid Advantage plans and state Medicare programs offering payment options.  However, there are still few buyers in the long-term care system for effective competition.  (Chies, 2021).

Moreover, in broad terms, government buyers (Medicaid and Medicare) have been dominating pricing through collusion.  Because of state and federal legislation and regulations, long-term care providers have had limited influence on the prices paid and the types of services provided. Also, government regulations have restrained long-term care competition through rulemaking and determining eligibility.  Other payment sources, such as MCOs and long-term care insurance policies have been able to gain a portion of the market, however, nursing homes and assisted living facilities are still predominantly covered by Medicaid and/or Medicare. (Chies, 2021).

Entry into the long-term care market was also difficult due to government regulations until the introduction of Certificate of Need (CON) legislation. And quality information was also hard to obtain until the introduction of the Centers for Medicare and Medicaid Services (CMS) Five-Star tool that provides information on regulatory compliance, staffing, and quality indicators. (Chies, 2021).

What might affect these strategies in the next 1 to 20 years (include competition from other health care organizations and what might change)?

The effect of these strategies within the next 20 years to increase competition may result in the increase of national and regional multi-facility long-term care chains. Single, privately-owned organizations have limited resources and will find it harder to compete. Furthermore, one major opponent to the long-term market is hospitals.  Hospitals already have the experience and built-in systems needed to enter the long-term care market. (Chies, 2021).

Example of what someone wrote

Hi Catherine,

Nice comprehensive post regarding how competition in the industry has evolved.

It was certainly an “easy ride” for those who owned nursing homes 20-30 years ago. Competition was not what it is today. These days companies have to come up with smart strategic ideas on how to  market their company and find a niche over their competitors otherwise they will not be able to sustain themselves. The good news for well established companies is that these days hospitals have a lot of pressure to discharge patients to nursing homes and other facilities quickly, mostly due to how they get paid by insurance and also to free up beds for their next patients.  As time goes on, there will be fewer sole owned facilities and will likely be bought by bigger corporations and hospitals. Solely owned facilities are no longer viable, all it takes is one or two lawsuits and they are wiped out.

Another aspect of good news for strong companies is that the elderly population is growing a lot and people are living longer so the need for these facilities will grow as well. The ones with the best services and care will ultimately come out ahead of their competition.

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