A Great Idea from Pennsylvania to Help Nursing Homes

by James C. Sherlock

Perhaps the Governor can call the General Assembly into special session to copy the best idea I have heard for a short-term fix to nursing home medical care.

The Pennsylvania House of Representatives has just passed the “Senior Protection Act” by a vote of 201-1 to appoint the state’s academic medical centers to take over responsibility for infection control, testing, surveillance and medical care supervision in the state’s nursing homes.

Says Pennsylvania Speaker of the House Mike Turzai:

“To ensure consistency of programs, response and study of clinical and public health outcomes, the legislation would establish a coordinated, collaborative public-private-partnership approach of regional health system collaboratives. These health collaboratives would administer/manage personnel, protocols, testing and expenditures to protect the seniors in these facilities.”

A 125-member Virginia COVID-19 Long-Term Care Facility Task Force was established on April 10. Go to https://www.vdh.virginia.gov/emergency-preparedness/ and click on Partner Briefing COVID19 Healthcare Coordination 5/8/2020 to find out what they have done.

It is yet another advisory panel. Perhaps it can take this up if it has not already. This initiative was in the form of a bill in the Pennsylvania General Assembly. I am not sure whether the Governor thinks he can legally order this move or not.

As in everything else, if the General Assembly could vote on this, it would better honor the republican form of government guaranteed to every state by the United States constitution.

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35 responses to “A Great Idea from Pennsylvania to Help Nursing Homes

  1. Terrific Idea. This is national tragedy and scandal. This goes to heart of that problem.

    And, just as importantly, it doesn’t lock up and shut down rest of the nation while its sends thousand of tracer snoops into people’s homes and lives, tracking them down and locking them too, for what amounts to in the vast majority of cases nothing of adverse consequence or the equivalent of the flu, while it creates herd immunity, as a vaccine would. The companion tactics are social distancing, and outlawing large groupings of people.

    • At last a practical approach!

      • well.. sort of… now you got more than one boss… and I’m quite sure the nursing homes are not going to go along with recommendations that increase costs… without objecting…

        I’m wondering just how much power and authority this group actually has… it’s almost like setting up another agency that is supposed to coordinate with the existing one. It sounds good on paper..but I see problems with the two entities trying coordinate their efforts and I can just imagine the nursing homes now having to deal with an additional regulator.

  2. SO Jim, you FAVOR testing and contact tracing in the nursing homes right?

    And you favor it for the White House?

    how about other businesses?

    • I don’t know what the white house is doing, but I don’t see how it realistically scales up to statewide tracing. There are a ton of issues. Privacy, the quality and social skills of the tracers and the scale of the requirements to name a few. Do tracers get access to police contact tracing systems? How would multiple intersecting traces be spotted and coordinated? What would the central record keeping requirement be? Who gets to see the records? Is there a penalty for not participating? What is it? Who would enforce it? And most of all in Virginia, the Virginia Department of Health is in charge? I’m sorry. Please see https://www.cdc.gov/coronavirus/2019-ncov/php/contact-tracing/index.html and https://www.cdc.gov/coronavirus/2019-ncov/downloads/php/Key-Information-to-Collect-During-a-Case-Interview.pdf Tell me that you think VDH can coordinate that across the state. I simply don’t.

      • These issues are substantial, but they are the gig if you’re going to do contact tracing…

        Aren’t there some states dong this and your view is that Va is just not up to the task but other states are – or are you of the view that contact tracing in general is a bridge too far in general for all states?

        Finally – this is not a “epistemology” issue – it’s a data/computer issue to support an epistemology need.

        This is not an impossible task. We do this already for other things – like “ancestry” or a wide variety of database applications like airline scheduling or toll road tolling…

        In terms of “privacy”, it’s a joke. Most folks phones are FULL of “tracking” apps – put there when they install apps they want – from Walmart to their Banks to Google Maps.

        We count cars on highways by capturing cell phone signals in cars as they go by.

        The point here is that the technology to do this does exist – but not in the epidemiology world – instead in the world of computer technology a lot like distance learning. It’s not the teachers – it’s the technology.

  3. Jim S., are the two Task Force documents available online?

    Long Term Care Facility Task Force
    A playbook to support LTCF efforts to request staffing support, secure testing supplies and/or conduct point prevalence surveys (PPS), request PPE, receive training on PPE and infection control protocols, and communicate outbreaks to staff, residents, and their families.

    A companion guide for Local Health Departments to help coordinate responses to COVID-19 Outbreaks in LTCF has been distributed.

    • Not that I can quickly find. You would think there would be a link on the VDH page, but not so.

    • re: ” LTCF efforts to request staffing support,”

      what does that mean? who would be providing the support?

      • We citizens have no idea.

        • This is one of those issues that deal with the essence of the difference between government and private-sector approaches.

          The govt often goes to how to accomplish the desired outcome without as much regard for costs as the private sector would.

          The private sector is going to focus on costs and how to accomplish something with the least costs.

          If the government ends up in charge of something the private sector is providing – it becomes a struggle to meet some minimum performance standard – at some acceptable cost.

          So we have this situation where the govt provides reimbursement for Medicaid – at such a price point that at least some in the private sector cannot meet that cost without cutting staff, which, in turn, results in not meeting the performance standard.

          So, here’s another question.

          Are thre nursing homes in Va (or the US) where a majority of the residents are paid for by Medicaid – AND they have high ratings on infection control?

          In other words, is this a doable standard with the right kind of management or is it pretty much a sad outcome most of the time if a home is majority medicaid?

          If the data is provided – it should be an easy spreadsheet function.

          If it IS TRUE that there actually are nursing homes with majority medicaid AND they have good infection control – then I would concur with the critics of VDH who say they are too lax.

  4. Pennsylvania is lightyears ahead of Virginia. The have “automatic vote-by-mail”, albeit new this year. Register, declare a party, select the option and all primary and general election ballots are sent to you without the need to request.

    They have a deal with the insurance companies to allow them to renew your car registration when it comes due.

    Their state income tax is flat rate at 3.07%. If you allow banks, brokers, etc., to withhold then that’s it… you’re done.

    Virginia — 400 years of tradition unhampered by progress.

  5. not seeing a date….

  6. thanks.. oops, yes… 😉

  7. Simple question. Pa state takes over testing previously done by private for profit or non profit health facilities? Is this right? Who pays for that?

  8. First of all, this is not yet law in Pennsylvania; it has passed only one house of the legislature.

    I have serious doubts if the two major academic medical centers in Virginia (UVa and VCU) would be willing to take on this responsibility. For years, there has been some urging that they assume the responsibility of providing medical care in Virginia’s prisons, only to have them resist. If they assume such responsibility for nursing homes, one can be sure that there will be a high cost attached.

    • yes. There is a cost to this. And someone is going to pay it – and it’s probably going to be taxpayers.. This has always been the ying and yang, push and pull of nursing homes… – at $200+ a day ($70,000 a year) – most ordinary folks, even middle income, don’t have that kind of money and Medicaid as a payer of last resort is always under pressure to keep down their bite from the States budget. Private sector nursing homes fight any new regulations tooth and nail… if they think it will add to their costs.

    • EVMS/Sentara, Inova Fairfax Medical Campus and now the joint Carilion/Virginia Tech medical school are three more academic medical centers.
      The cost of this intervention would need to be paid. I don’t know the cost, and neither does the Governor, but it will need to be calculated. I expect that CMS would pick up a significant part of the cost, but Virginia would need to increase Medicaid nursing home reimbursements – half federal money – to cover the rest.
      The change would turn the academic medical centers into the regulators of the practice of medicine in nursing homes in place of VDH, which has failed to take on the task. VDH likely would still do the annual inspections for CMS, but the medical centers would oversee the medical performance of the nursing homes throughout the year. There is enough data already to do the job effectively, but VDH does not. The details of this program would need to be spelled out in law, including the budget impact. That is why the GA needs to get involved.
      All of that being true, this is the only pathway I see to actually improving medical care in nursing homes in Virginia.

      • Yes, if deal includes establishing firm highly enforceable protocols that insure this never happens again, because we get these people real health care, instead of what apparently we now have all over nation, too often little more than infection death traps for most vulnerable.

  9. If for profit organizations won’t meet basic standards of care and academic medical centers need to be brought in to supervise improvements, couldn’t fines on the deficiencies be used to cover the cost? Why should a group continue to profit by failure to meet adequate basic care goals?

  10. What happened to the free market? Are we back to the 1920s poorhouses yet?

  11. I was gonna say… for all the long-winded discussions we have here in BR about how incompetent government is and especially so do-gooder liberal type govt – this thread sure has gone out the wazoo on having the govt do something!

    Pretty sure Centers for Medicare & Medicaid Services already do fines.

    Throwing another govt agency into the mix here so that you’d end up with Centers for Medicare & Medicaid Services, the State agency and then an additional academic-based one – all 3 on private sector businesses doesn’t bode well for reducing overlapping roles as well as increasing costs.

    Folks should take a harder look at this in terms of asking what would happen if the Govt – yes that big, bad, wasteful, incompetent government STOPPED providing Medicaid for nursing home care which is clearly beyond the means of a lot of people, way more than just the poor – even middle income people would be hard-pressed to come up with 70K a year for care.

    We yammer on and on here in BR about the “outrageous” costs of Higher Ed, taxes, regulation, CPN, licensure, and the “free market” but here we argue for MORE govt and MORE taxpayer money to fix a problem that is NOT created by government in the first place.

    Can the folks here in BR who normally argue for the free market and less government “interference” , taxes, regulation etc… can ya’ll weigh in on this just a tad?

    Are we REALLY arguing for MORE govt, more regulation, higher taxes, and less free market as the solution? GAWD!

  12. We could lower the cost if we put Granny to work. She could assemble N95 masks or sew protective gowns. Time to get their lazy butts back to work.

  13. It’s not MORE government, it’s more EFFECTIVE government.

    The federal and state governments contribute to the revenue stream of nursing homes and other long term care facilities through Medicare and Medicaid. Families who have sufficient income pay LTCFs directly.

    The Virginia Dept of Health and Health Board are responsible for seeing that LTCF meet the standards established by regulations. They have failed to see those standards are upheld in too many facilities. Fines are assessed and are treated by LTCF owners as a cost of doing business without any guarantee of change.

    The state has a duty to its citizens to fulfill its obligations to protect the health, safety and welfare of the citizens least able to protect themselves. If shifting LTCF supervision to academic/medical organizations instead of the VDH/Board of Health, while VDH/BoH retain their inspection functions, the owners who failed in their responsibilities in the first place should have to cover the cost of correcting what those owners should have seen to in the first place–whether that is through deficiency fines or fees. Owners who meet the basic “average” ratings wouldn’t need the academic/medical supervision, and wouldn’t have deficiencies and fines. Those who failed to do so would pay for correction of their failures.

    • re: ” It’s not MORE government, it’s more EFFECTIVE government.”

      shouldn’t it be MORE COST EFFECTIVE GOVERNMENT?

      If our view of “more effective” does not also address costs – then in the end, are we not just throwing more govt bureaucrats (yes that’s what those academic guys woul become) and more tax money and imposing higher staffing costs on the private sector?

      We have (I think) about 30,000 folks in long term care facilities in Virginia and it costs one fourth of the nine BILLION in Medicaid costs – about $70,000 a year per resident.

      This is far more than most of those folks earned when they were younger and working… and obviously far more than they had set aside for their final years.

      Before we BLAME the long term care facilities – we ought take a harder look at how we have ended up this way and WHY it costs 70K a year to care for people to start with.

      Again, sorry to sound so very Republican but these threads – written by “conservatives” has steadily trended to more govt and more tax dollars and more regulation – totally out of character for most Republicans…!!!

  14. I had asked before – and will again. Is this a problem of not enough money for the task or is it a lack of good management to utilize the finances available cost effectively?

    So how would you know?

    One way is to ask if Medicaid actually does provide enough money to get the job done – i.e. are their nursing homes in Va and the USA that are predominately funded by Medicaid (i.e. have a high percentage of medicaid residents) AND also earn acceptable or good infection control ratings?

    If there are, then we should look at them to see how they are successful and if what they do is different from what the ones that don’t do well, do.

    In other words, BEFORE we go off on the blame game and what I consider outlandish “solutions” that will lead to even more administrative costs at the regulator level AND higher nursing home costs if more staff is mandated – before we do that – how about we do a proper analysis of the issue THEN decide AND make changes WITHOUT adding increased regulations, administrative and staffing costs.

    If in the end, we THINK that the basic problem is that Medicaid reimbursement is in sufficient to pay actual costs – then the added academic function is not going to solve the basic problem, and we need to confront the reality that reimbursement costs is a major driver.

    “Conservatives” used to “work” this way. Their focus was on cost-effectiveness over throwing more money and regulations at the problem.

    Now, because we have partisan blame games, the nursing home traged is being used as a political weapon… without regard to good old fashioned cost-effectiveness analyses.

    Right now, unfortunately the time is ripe for knee-jerk responses to the nursing home problem. And this drives the politics of finding who is responsible and punishing them… with more regulations, enforcement and fines rather than actually fixing the real problems.

    For some perspective, we spend about $1000 a year for every man, woman and child in Virginia to pay for medicaid for nursing homes.

    Are we advocating increasing that cost as a solution to the problem or can it be fixed through changes that are actually MORE cost-effective?

    I know.. I know. This sounds like a Conservative Republican… sorry about that.

  15. Larry, you’re off into nonsense again. 57.5% of the nursing homes meet their standards and stay in business.

    • that’s not a particularly useful number Carol – totally lacks any context with regard to what is proposed to be fixed and the cost of doing so.

      I am NOT opposed to fixing these issues – it IS terrible that we have so many of our elderly in such tenuous circumstances – and most of the time, most of us could give a rats ass about it until now….

      I really am asking if the ANSWER to this problem is MORE tax money, more regulation and more govt ?

      Totally odd for someone who is often called a “liberal” to have to ask this question on threads written by a Conservative?

      WEIRD!

  16. Larry,

    It’s the usual cause of all problems. All reporting and monitoring, all necessary and important functions of government and business comes down to someone who is paid $10/hr.

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