Long-Term Care Providers Assume a Starring Role in a Tough Healthcare Environment

The long-term care (LTC) environment is heavily regulated, and many LTC providers have adapted to several waves of change, large and small. Some of us remember when the Omnibus Budget Reconciliation Act (OBRA) of 1987 was implemented and the hurdles we had to overcome. Now we find ourselves in the midst of yet another period of change and challenge as the Centers for Medicare & Medicaid Services (CMS) implements the prospective payment system (PPS) for fiscal year 2012. Providers are under intense pressure to understand and comply with the new rules and are working longer hours to make the changes mandated by CMS. During the struggle, many in LTC have likely considered moving to other areas of healthcare or even out of healthcare, but it is against our nature to give up. Time and time again, we apply our ingenuity and compassion to conquer whatever new obstacles are laid in front of us, doing whatever it takes to succeed. To put things in perspective and give you an even greater appreciation for how far LTC providers have come and what we can do, let’s review of some of our most significant accomplishments in the past two decades of major change and increasingly challenging regulatory oversight.

Implementation of OBRA 1987

OBRA 1987 ushered in a world of change for LTC—and introduced more controversy to the survey process. It created the Minimum Data Set (MDS), adding new, more specific regulations to the survey process and forever transforming how facilities assess their residents. The MDS represented an assessment tool that was “standardized and reproducible,” in preparation for a national computerized system. Never had such a complicated system of assessment been mandated in a healthcare setting. For years, the MDS was completed by hand on paper, with the hard copy maintained and used for review. When OBRA 1987 was implemented, few LTC facilities had a computer outside of the billing office and many nurses did not know or did not want to know how to operate one—they were too busy taking care of people. Today, we recognize the role the MDS played in improving the skills and knowledge of assessors as they learned to work within the new system. Quality of care also improved as a result of the diligence, commitment, and resourcefulness of LTC providers.

MDS 2.0 and Enforcement Requirements

In 1995, CMS introduced version 2.0 of the MDS (MDS 2.0) along with enforcement requirements. Providers once again made a conscientious effort to educate themselves on these new programs and manage their implementation effectively. The MDS 2.0 was more advanced and clearly designed to prompt LTC facilities to move toward computerization. As facilities added computers, nurses and other healthcare professionals learned how to use them and to work within the digital environment. Enforcing the MDS 2.0 was complicated and more than a little intimidating, with a myriad of penalties, scope and severity determinations, remedies, and civil money penalties (CMPs). As a result, the Informal Dispute Resolution (IDR) was born. Although the IDR was not ideal, an increasing number of providers began to realize the importance of using their right to dispute improper findings and inaccurate statements of deficiency. Statements of deficiency are a matter of public record; if they are inaccurate, incomplete, unjustified, or lacking valid information relevant to the issue cited, they misrepresent how a facility conducts itself and cares for its residents. Every facility cited improperly for a deficiency should use all avenues at its disposal to refute the citation, something many providers have done successfully.

Electronic Transmission of MDS Information and the PPS

As of June 22, 1998—just 10 days before the commencement of the PPS—facilities were required to submit MDS data electronically to the state to receive payment. This was the first time that payment was linked directly to the MDS, frustrating healthcare providers. Staff had a hard time adapting to the procedures for data transmission and determining whether transmissions were successful. Some of you may remember the confusion over “fatal errors,” a lousy term to use in a healthcare environment and a source of conflict between nurses and software vendors. As if matters were not complicated enough, certain assessment combinations had not been assigned Health Insurance PPS (HIPPS) codes, and fiscal intermediaries (FIs) would not accept the charges. That oversight led to months’ long delays in reimbursement for some facilities.

The story behind MDS transmission and PPS implementation at the government level is an interesting one. CMS, known then as the Health Care Financing Administration, trained FIs on the PPS but not on the MDS, despite many thinking that the MDS was just as new as the PPS. CMS denied requests from state coordinators for the MDS and Resident Assessment Instrument (RAI) to be trained on PPS. Once PPS was in place, no one had answers to the multitude of questions that arose from putting it with the MDS. LTC providers made their voices heard, however. They studied the problems, asked questions, and actively sought solutions, looking for innovative ways to operate effectively and efficiently within the new system. Ultimately, solutions were found or developed, and, with patience and endurance, LTC providers mastered the PPS.

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Quality Indicators and Quality Measures

In the 1990s, surveyors began using quality indicators in an attempt to ascertain a facility’s deficient practices before conducting an inspection. Previously, the survey process had always considered a facility “in compliance” prior to identifying an evidence-based deficiency while on site. Now, potentially deficient areas were being targeted before the surveyors had left their offices. 

Although these aren’t the only changes that occurred, they provide  a brief synopsis of life in LTC in the 1980s and 1990s, in which LTC providers met every demand and continued to thrive. We became proficient at scrutinizing the rules and regulations and developing mechanisms for success. It was difficult and painful, but we are proud of how we rose to the occasion and met the goals set for us.

Ushering in the Next Generation of LTC

Today’s new LTC providers are stepping into some big shoes as this next decade introduces new challenges. The 11.1% in budget cuts for fiscal year 2012 are record-breaking, and the growing focus on “payment accuracy” and audits to recoup “overpayments” is expected to be staggering. According to the government, the emphasis on payment accuracy and overpayments is to recoup money that facilities never should have been paid. The auditors—Medicare Administrative Contractors, Comprehensive Error Rate Testers, Recovery Audit Contractors, Zone Program Integrity Contractors, Medicaid Integrity Contractors, and Payment Error Rate Measurements—are all looking for money to reclaim. Now, more than ever before, LTC providers will be challenged to learn about proper diagnosis coding and documentation to support Resource Utilization Group categories.

With significant reimbursement cuts  for fiscal year 2012 and more cuts possibly looming on the horizon, it is important for LTC providers to get ahead of the game. They must make changes to prevent their facilities from losing additional money because of inadequate or incorrect documentation and improper diagnosis coding—money that has already been spent on providing care for their residents. Staying informed is essential for overcoming the challenges that lie ahead. Changes occur almost daily, and those who are aware of these changes are the ones most likely to be left standing.

One might expect LTC to fail in the face of such constant change. In reality, the last few decades of change have taught LTC providers to become increasingly resourceful and fiscally responsible as a matter of good business. The 2011 budget did not fail because of intentional fraudulent practice, but instead because budget predictions were astoundingly inaccurate. Further, LTC was not given credit for being able to respond to regulatory changes efficiently and effectively while continuing to function within the rules CMS put forth.

LTC providers have learned to fend for themselves the hard way, and facilities abide by the rules. Despite seemingly insurmountable opposition and reimbursement that is often inadequate, LTC facilities continue to provide care for residents who need it, making them real stars in the healthcare industry.

Ms. Mullins is director of research and development, The Compliance Store. She has more than 33 years of experience in healthcare, having held positions as MDS coordinator, state surveyor, state RAI coordinator, and OASIS education coordinator for the State of Alabama. She is also the author of The MDS Coordinator’s Field Guide and a clinical advisor for the AALTCN.