COLUMBUS, Ohio – Older Ohioans in nursing homes or receiving home-based care could see a big boost in state funding under an Ohio House framework that significantly changes the governor’s proposed budget.
The budget still faces a long road. The House will make further changes this week, and the Ohio Senate is yet to weigh in with its own priorities. The two sides eventually will hammer out a compromise ahead of a June 30 deadline to send the budget to Gov. Mike DeWine.
But the House’s current proposal would deepen investments in nursing homes – a pandemic-ravaged industry known for its political clout at the capitol. That includes an amendment that allows previously appropriated coronavirus relief dollars to flow to some of the most well-off facilities in the state, prompting one of its few possible recipients to describe it as “greedy.”
One big change would compel Medicaid to pay providers extra money to put residents in private rooms, something the program has historically shied away from.
In a shift, however, the House budget reflects new spending in assisted living and other home and community-based care, which keeps people in their homes and is much cheaper than skilled nursing care.
“I think this budget goes a long way to supporting older adults in this state in terms of living in their homes and communities,” said Beth Kowalczyk, the chief policy officer for the Ohio Association of Area Agencies on Aging.
“It would appear that people recognize that there is a system, and all parts of the system need to be supported.”
Medicaid is a health insurance program funded by state and federal governments that covers lower-income Americans. It’s also the primary payer for long-term care in the U.S., paying costs for 60% of nursing home residents, according to the Kaiser Family Foundation. Billions of dollars flow to Ohio long term care providers each year.
Currently, home care workers who help older patients with things like changing, cooking, and cleaning make around $10 to $12 an hour through Medicaid reimbursements, Kowalczyk said. Lower wages lead to a labor shortage and blow a hole in the market. DeWine’s budget called for increasing those wages through reimbursements to about $16 an hour. The House went even further to $18.
The budget also provides for a 48% increase in the state’s Medicaid-funded assisted living waiver program, which can keep people in their homes and hopefully avoid some of the steep costs of skilled nursing or long-term care, according to Patrick Schwartz, an industry lobbyist.
Nursing homes
While some budget lines amount to a victory for home-care patients, few industries won as big as nursing homes in the House budget.
It increases the frequency with which the industry can “rebase,” or adjust cost reimbursement figures for inflation. It reworks the state’s quality incentive program, rewarding homes with higher occupancy rates. And it offers an add-on payment to facilities that put Medicaid patients in private rooms – a break from a general practice of Medicaid declining to pay for private rooms.
Those changes could help prop up homes with dwindling census counts. However, supporters of the private room idea – which includes virtually everyone interviewed by Cleveland.com / The Plain Dealer – said most residents want their own space for their dignity, comfort, and peace of mind. Plus, it doubles as an infection control measure – several COVID-19 outbreaks ripped through Ohio nursing homes aided by residents sharing rooms and passing around the sometimes-lethal disease.
One House amendment would allow some of the $350 million in previously appropriated federal coronavirus relief dollars to flow to roughly six nursing homes that aren’t enrolled in Medicaid. Those more upscale facilities cater to people with private insurance.
Scott Gibson is the executive director of The Kenwood in Cincinnati, a private payer facility that he referred to as one of the nicest nursing homes in the country. He said the facility wouldn’t accept public money, calling the amendment “greedy.”
Pete Van Runkle, executive director of the Ohio Health Care Association, one of the most powerful industry lobby groups in Ohio, emphasized in an interview he had nothing to do with the amendment. Chris Murray, the executive director of the Academy of Senior Health Services, said the same.
The amendment came at the behest of GOP Reps. Bill Seitz and Jim Thomas, both of whom have such facilities in their districts. Both defended the amendment, arguing the pandemic ravaged every facility, not just the more modest homes.
Quality incentives
Van Runkle said he’s pleased with the budget so far. He said considering occupancy as a quality metric may sound out of place, but it relies on the market-based premise that superior facilities will tend to attract more demand.
More money in this cycle’s budget, he said, is tied to new metrics the federal government already tracks to assess quality like rates of residents who can independently perform tasks of daily living, rates of falls, and rates of residents on anti-psychotic medication. He also praised a change in the system that rewards facilities that score a certain number of points, rather than only rewarding a fixed percentage of facilities and cutting off the rest.
“The cutoff is kind of arbitrary and kind of unfair,” he said. “When we add so much money to quality incentives that it basically becomes part of the base rate, we feel like everybody should get credit or discredit.”
Jackie DeGenova serves as the State Long-Term Care Ombudsman. She said her office fully supports DeWine’s budget and said there is “much work ahead in discussions on rebasing” and said she agrees that this must come with a serious discussion about quality of care.
According to data she provided, most the complaints her office received in 2022 revolved around discharge/eviction (588); personal hygiene (477); symptoms unattended (465); “respond to requests for assistance” (441); medications (400); followed by care planning, dignity and respect, living restrictions, personal property and food services.
DeWine cast a spotlight on problems in state nursing homes during his state of the state address, noting that Ohio ranked 39th among states in the most recent ranking from the federal Centers for Medicare and Medicaid Services quality star system. He said any rebasing discussion will also include a “serious discussion about quality” in nursing homes.
“Tragically, nursing home horror stories happen in every part of the state,” he said. “I have received gut wrenching letters from families asking for help.”
‘Public policy favoritism’
The good feelings on the budget aren’t universal among those familiar with the industry.
For 30 years, there has always been lofty rhetoric about improving quality of Ohio’s nursing homes, said Greg Moody, who served as a point man on health policy for Gov. John Kasich as the former governor unsuccessfully tussled with the industry. But Ohio never seems to improve, and Moody attributed this in part to quality metrics that reward underperformers.
“There’s an agreement that money should go toward quality, but the money tends to be given to everyone,” he said. “If most homes benefit from a quality formula and get paid for it, there’s something wrong with it.”
Moody said he’s “wary” of a budget that lets public money flow to wealthy facilities that don’t need it. He noted that while some previous appropriations have required that money flow directly to caregivers, the budget makes no such requirements.
“This is about workforce, about workforce contributing to quality, and who should have a say in that,” he said.
A representative with SEIU 1199, a union representing health care workers, didn’t respond to an inquiry. A spokeswoman with AARP Ohio said the association, a key stakeholder in budget fights, is still reviewing the proposal.
The House budget also contains one amendment that decreases training requirements for home health and personal care aides, as noted by Loren Anthes of the Center for Community Solutions.
Joe Russell, executive director of the Ohio Council for Home Care and Hospice, said he’s thankful House lawmakers and DeWine’s administration recognize the need to boost home care workers’ wages before the industry “collapses.”
But he said those wage hikes only apply to personal care workers as opposed to the higher-skill and pricier positions like nurses.
In the big picture, he said the nursing home industry – which pumps huge money into lawmakers’ campaign accounts every cycle – tends to get its way.
“It’s just a fact of the matter that both of our industries provide a lot of services to the geriatric population, and there is a clear public policy favoritism to one industry over another,” he said.
This article was clarified to reflect that some of, not the whole, $350 million in previously appropriated funds can flow to private payer only nursing homes under the bill.
Jake Zuckerman covers state policy and politics for Cleveland.com and The Plain Dealer.