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Statement for the RecordCaring for Aging AmericansNovember 14, 2019Mr. Chairman and Mr. Ranking Member, LeadingAge appreciates the opportunity to submit this statement for the hearing record. Our members have a long history of service to older people and we greatly appreciate the committee’s focus on these important issues.We represent more than 5,000 aging-focused organizations that touch millions of lives every day. Alongside our members and 38 state partners, we address critical issues by blending applied research, advocacy, education, and community-building. We bring together the most inventive minds in our field to support older adults as they age wherever they call home. We make America a better place to grow old.All LeadingAge members are not-for-profit. About 75% of our members had their origins in faith-based communities; others were established by fraternal or cultural organizations. Some have served their communities for over 100 years.People come to need a wide variety of services as they age. We appreciated the range of issues committee members and witnesses addressed at the November 14 hearing. Some of the areas where public policy matters and where we would like to work with the committee on solutions include:Long-term services and supports financing: Recognizing the inadequacy of the current patchwork of long-term services and supports financing, heavily dependent as it is on Medicaid and unpaid informal caregiving, LeadingAge began working in 2004 to develop proposals for a better system. We are very pleased that this issue was discussed during the committee’s November 14 hearing.By 2030 more than one in five Americans will be over the age of 65, with a 50% possibility of needing paid long-term services and supports before they die and few options to pay for it through either public programs or private savings. LeadingAge recommends a dignity-driven and universal long-term services and supports insurance program grounded in the principles of shared risk and consumer flexibility. We are encouraged that you, Chairman Neal, along with Rep. Frank Pallone and other members of Congress are beginning to grapple with this complex issue. We were also interested to hear comments at the hearing on Washington state’s new long-term care financing program, which will finance a capped amount of long-term services and supports with a dedicated payroll tax. We firmly believe that the nation’s current methods for financing long-term services and supports are unsustainable, irrational, and unfair for individuals and families. It is estimated that about half of all older adults will lose the ability to care for themselves during their lifetimes and will need help with everyday activities. We commend all of those addressing this critical issue and we will continue to work with them to frame and support workable solutions.Affordable housing: A place to live is a basic human need and the bedrock of home- and community-based long-term services and supports. Older people without a decent, affordable place to live have difficulty accessing whatever other services they may need to remain in their communities. Affordable housing enables residents to receive long-term services and supports cost-effectively in comparison to other kinds of long-term care.The supply of federally subsidized affordable senior housing lags far behind the number of people seeking it. In many communities, the waiting list for an apartment is years long; other communities have closed their lists completely due to the lack of foreseeable availability. A typical comment from one of our housing members at a 2018 town hall meeting:Some of the 3,600 people on my wait list tell me, “I've applied. You have a five-, six-, seven-, eight-year waiting list. I get $1,100 a month from social security. My rent in my apartment is $900 dollars a month. I can get some SNAP (food stamps). You know, I'm eating cat food at the end of the month, what can you do for me? Nothing.” That’s the heartbreaking conversation that we have constantly. Solutions and recommendations:Annual appropriations sufficient to cover the costs of preserving, maintaining, and operating existing affordable housing projects and building new ones. Funding also should be expanded for the service coordinators who assist residents in accessing the supportive services they need.Expansion and improvement of the low-income housing tax credit, an essential tool to leverage private investment in affordable housing.Preservation of the tax-exempt status of private activity bonds, which many communities use to finance affordable housing for seniors.Affordable housing combined with supportive services: Safe and secure housing can become a platform for the cost-effective delivery of services that enable residents to remain in their communities and also avoid hospitalizations and use of other expensive forms of health care.This potential is illustrated by a demonstration program under which enhanced services in affordable senior housing were provided to about 400 older adults in greater Boston. Researchers studied the impact of Hebrew SeniorLife’s Right Care, Right Place, Right Time initiative—known as R3—on older adults living in multiple senior communities over an 18-month period and compared results with the experience of older adults in similar buildings who did not receive the R3 intervention. “There were statistically significant changes in health care utilization over that period that we believe can be attributed to the program, the so-called R3 effect,” said Marc Cohen, Ph.D., the co-director of the LeadingAge LTSS Center @UMass Boston.Home and Community-based services: Most people would prefer to remain at home and in the community when they need long-term services and supports. LeadingAge members provide an ever-increasing array of home and community-based services (HCBS). We support policies that give HCBS providers the ability to deliver the highest quality care that complements informal caregiving by family members and friends.Solutions and recommendations:Implement the HCBS settings rule in a way that promotes services in the most integrated settings without impeding the ability of aging services providers to deliver appropriate care. The settings rule is CMS’s attempt to ensure that beneficiaries receiving Medicaid-covered home- and community-based services are living independently in communities. However, the rule has made it difficult for many residents of assisted living or of housing located on the campus of residential facilities to access the supportive services they need because their housing has to meet “heightened scrutiny” tests as to whether it is sufficiently community-based.Reauthorize the Older Americans Act (OAA) in a robust way to support 21st century aging services. The OAA is a highly efficient and cost-effective mechanism for providing the basic services millions of older people need in order to continue living in community-based settings. LeadingAge supports H.R. 4334, the Dignity in Aging Act, which would extend OAA’s authorization through fiscal 2024. We are especially pleased that the bill includes provisions to include long-term care among the employment options to be made available to older workers under Title V of the OAA.Nursing homes: With increasing longevity, changes in family dynamics, geographic mobility, and other factors, a good nursing home often becomes the best place for people to receive the care and services they need. A typical nursing home resident is aged 85 or over, unmarried, with dementia and/or an incapacitating chronic condition. Half of nursing home residents have no children or other informal caregivers available, others have care needs that exceed their families’ ability to provide for.LeadingAge’s nursing home members have led the field in innovations that have elevated standards of care. Since its founding in 1961, LeadingAge has stood for quality nursing home care. We participated in the development of the Nursing Home Reform Act, enacted as part of the Omnibus Budget Reconciliation Act of 1987 (OBRA ’87). We have worked with the Centers for Medicare and Medicaid Services on the development of regulations to carry out OBRA. We have taken leadership roles in numerous initiatives like Quality First and Advancing Excellence in America’s Nursing Homes, designed to give nursing homes tools and accountability measures to improve care. We and our 39 state associations provide extensive educational resources for our nursing home members not only on regulatory requirements and how to comply, but also on the deeper and more extensive issues of developing sound and forward-thinking leadership, recruiting and retaining well-qualified staff, and best practices for meeting the challenges of caring for extremely frail and vulnerable people. Our goal and vision is for every nursing home in the country to be a place where any of us would be willing to live if we needed the level of care nursing homes provide.Some recent examples of quality enhancement efforts our members and state associations have initiated: Safe Care for Seniors, a program spearheaded by LeadingAge Minnesota, is designed to eliminate preventable harm in the course of caregiving. Providers, team members, residents and families partner together to promote a culture of safety that allows residents to thrive in a community built on safety, trust, dignity, and respect. Gayle Kvenvold, President and CEO of LeadingAge Minnesota put it this way: “…we began by asking this question: what is in our power to do to bring about the best lives for our elders? And that led us to renew our commitment to the heart and soul of our work – respect, safety and dignity for those we serve – and to commit as a statewide caregiving community and as LeadingAge Minnesota to some of the most meaningful work we will ever do.” Another example involves two of our member nursing homes’ collaboration with Altarum in its Program to Improve Eldercare. Altarum has received funding from civil monetary penalties collected by the state of Michigan for a three-year nursing home culture change initiative. LeadingAge members Martha T. Berry Medical Care Facility in Mount Clemens and Beacon Hill at Eastgate in Grand Rapids will be two of the six nursing homes participating in this initiative. This “Accelerating Quality Improvement for Long-Stay Residents in Michigan Nursing Homes Using Culture Change” project will involve education and coaching from the Eden Alternative, a well-known proponent of fundamental nursing home organizational transformation toward truly person-centered services. Project participants will be trained in directing their organizations’ operations to services oriented by resident choices and values. We also want to mention the work done by RiverSpring Health in Riverdale, New York. In addition to comprehensive services for its residents, RiverSpring maintains the Weinberg Center for Elder Justice, established in 2005 as this country’s first shelter for victims of elder abuse. At the Weinberg Center, elders who have experienced physical, emotional, or sexual abuse; neglect or abandonment; or financial exploitation can find shelter and help to regain control over their lives. Multi-disciplinary teams at the Weinberg Center provide trauma-informed care and services to help the older person recover, deal with legal issues, and often return to the community. RiverSpring Health is part of the Shelter Partners Regional, National, & Global (SPRING) Alliance, a growing network of regional shelters supporting older people who have been victims of elder abuse. Several other LeadingAge members have joined the Alliance, including Eliza Bryant Village in Cleveland, Ohio; St. Elizabeth Community in Providence, Rhode Island; Lifespan in Rochester, New York; Jewish Senior Life in metropolitan Detroit, Michigan; and Jewish Senior Services in Bridgeport, Connecticut. These organizations collaborate, sharing resources, technical assistance, and training to serve elders who have experienced abuse.These are only some of the examples of the work LeadingAge members do every day to ensure the highest possible quality of care and quality of life for older people who need long-term services and supports. ChallengesWe and our members understand that no one aspires to live in a nursing home. All of us would prefer to live independently until we die. But with increasing longevity, changes in family dynamics, geographic mobility, and other factors, a good nursing home often becomes the most humane and cost-effective place for people to receive the care and services they need. A typical nursing home resident is aged 85 or over, unmarried, with dementia and/or other incapacitating chronic conditions. Half of nursing home residents have no children or other informal caregivers available, others have care needs that exceed their families’ ability to provide for.Nursing homes are essential, and their continued health and survival should concern us all. Our sector is struggling under current financing and regulatory systems. Without a public policy turnaround, these caregivers of last resort will no longer be able to provide a safety net for hundreds of thousands of older people and their families.Since June 2015, over 549 nursing homes have closed. More than 40% of those nursing homes had four- or five-star ratings on the Centers for Medicare and Medicaid Services (CMS) Nursing Home Compare rating system. Many of the ones we are losing are the good ones.Rural nursing homes are closing at about the same rate as urban and suburban nursing homes, but their closures have more impact in rural states where there are few alternative long-term care providers. For example, the New York Times reported earlier this year on the impact of closures of rural nursing homes in South Dakota. In addition to the impact on residents, who may have to find care in a nursing home much farther from their families and friends, closures of rural nursing homes can hurt communities where they were a large, stable employer.CliftonLarsenAllen (CLA)’s 34th Skilled Nursing Facility Costs Comparison and Industry Trends Report, issued on October 10, found that for the first time since CLA began collecting this data, “the median operating margin has dipped below zero (and currently sits at -0.1%).” According to the report, financial trends are leaving nursing homes struggling to generate enough cash flow to cover operations, forcing them to borrow more to meet basic expenses, and as a result having few resources to reinvest in their communities. CLA noted the number of news reports during this past year on closures, receiverships, and bankruptcies, “particularly in states where Medicaid rates are among the lowest in the country.”The relationship between Medicaid payment rates and nursing homes’ ability to continue providing high quality care is too often ignored. Medicare pays for less than a quarter of nursing home services, and private insurance covers about ten percent. Medicaid is the primary source of payment for nursing home care, covering 62% of services. In its March 2018 report, the Medicare Payment Advisory Commission (MedPAC) stated, “Medicare payments . . . effectively subsidize payments from other payers, most notably Medicaid.” (page 228). LeadingAge has non-profit member nursing homes that maintain high quality services despite the challenges of Medicaid under-reimbursement. But Medicaid shortfalls can leave nursing homes unable to offer the salaries and benefits available in other settings. Recruitment and retention of well-qualified staff are critical to nursing homes’ ability to provide high-quality care. A reexamination of the federal-state nursing home regulatory system is also in order. LeadingAge collaborated with other stakeholders in the development of the Nursing Home Reform Act when it was incorporated into the Omnibus Budget Reconciliation Act (OBRA) of 1987. Our members have led the nursing home field in innovations that have elevated standards of care. Much has been accomplished in our field since OBRA’s enactment, including the virtual disappearance of physical restraints, substantial reduction in the inappropriate use of antipsychotic drugs, and growing adoption of person-centered care practices and culture change.Yet these accomplishments seldom get any credit or recognition. The prevailing assumption seems to be that if nursing homes work hard to provide high quality care and follow all the rules, they will not have anything to fear from the federal/state oversight system. If only that were the case.LeadingAge absolutely does not apologize for or defend bad care. However, the continued emphasis on punishment does not appear to be working to achieve the kind of nursing home care all of us want to see. OBRA ’87 has been in effect for more than 30 years, and over those decades has been “strengthened” administratively a number of times. Yet many of the requirements can be subjective and survey agencies’ evaluation of compliance varies from state to state and region to region, as reported by watchdog agencies like GAO and the Office of Inspector General.Solutions/recommendations:The Government Accountability Office (GAO) should examine state and federal payment issues and make recommendations on better federal oversight of Medicaid reimbursement rates to enable nursing homes to meet the actual costs of care.When public policies such as federal or state minimum wage increases are adopted, Medicare and Medicaid post-acute and long-term care reimbursement rates must be raised to reflect the higher costs. Labor costs constitute approximately 70% of nursing homes’ annual budgets. Because public programs pay for such a large volume of long-term care services, providers cannot simply raise prices as other businesses do in response to added costs.Congress should obtain an evaluation of the current federal/state oversight system’s effectiveness and potential improvement by an objective, independent third party like the Health and Medicine Division of the National Academies of Science, formerly known as the Institutes of Medicine (IOM). Reports by the IOM on quality issues in nursing home care gave rise over 30 years ago to passage of the Nursing Home Reform Act/OBRA ’87. While much as been accomplished in the decades since, quality issues remain at the same time that high-performing nursing homes are burdened by a highly prescriptive and antagonistic oversight system. In particular, the CMS Five-Star nursing home rating system needs overhauling to give today’s consumers the information they need to choose good nursing home care. Contrary to the five-star systems so pervasive on the internet for rating other goods and services, the CMS system rates nursing homes on a bell curve, allowing only a limited number of homes to qualify for four or five stars. This dissonance between what most consumers expect of a five-star system and the actual meaning of the CMS system makes it ineffective as a tool for consumers to gauge the quality of care at any one nursing home. Hospice: LeadingAge is supportive and engaged with the Committee and with Rep. Panetta’s and Rep. Reed’s offices regarding legislation in response to the July 2019 Office of the Inspector General reports on hospice care. LeadingAge’s hospice members are all nonprofits but run the gamut in terms of whether they are freestanding, home-health based, hospital based, or skilled nursing facility-based.LeadingAge supports increased oversight to prevent harm to patients and families. We also want to be sure that any remedies that result from increased scrutiny authorized by Congress and implemented by CMS are targeted at poor performers, transparent in their tactics and goals, and that all parties, including oversight authorities, are accountable for pushing for improved performance. We also note that media attention from these reports focused on a very small number of poor performers and connected those cases to larger patterns of deficiencies without distinguishing between types or degrees of deficiencies in a clear way. This lack of clarity is what we would like to avoid in legislation and CMS implementation of new oversight policies so that LeadingAge members can continue to provide excellent care. LeadingAge is supportive of the goals of improving the transparency of the survey and deficiency data available across all types of survey entities, creating more educational outlets, improving Hospice Compare, and authorizing alternative remedies to be used in targeted and appropriate circumstances. We ask that the Committee consider the following specific recommendations in their broader approach:Targeting the information on Hospice Compare to be focused on deficiencies related to quality of care with clear explanations as to what the data means and why it is important to beneficiaries;A requirement that stakeholders be consulted regarding hospice compare changes and language and that the stakeholders include trade associations, patients, caregivers, hospice providers, and others deemed appropriate by the Secretary;Making sure that there are requirements for joint training of state and local survey entities, accreditation organizations, Medicare Program Integrity Contractors, Medicare Administrative Contractors, and hospice providers;A stepwise approach to intermediate remedies starting with in-service training, moving on to directed plans of correction (which can be directed by a temporary manager or the Secretary) with specifically defined and transparent goals, followed by payment suspension when other remedies have failed. Additionally, all intermediate remedies should have a clearly defined appeals process. We look forward to continuing to work with the Committee on the content of this legislation and on future issues related to the hospice benefit and broader issues in end-of-life care.Long-term services and supports workforceThe US has a significant shortage of, and a growing demand for, qualified workers who are capable of managing, supervising and providing high-quality services and supports for older adults. The population of adults age 65 and older will increase from nearly 50 million in 2015 to 88 million in 2050 – an 84% increase. Among those currently reaching?retirement age, more than half (52%)?will require long-term services and supports at some point, and?for an average of two years. By 2050,?the number of individuals using paid?long-term services in any setting will likely double?from the 13 million who used services?in 2000, to 27 million people.? Thus, the nation will need 2.5 million workers of all different types by 2030 to keep up with the growth of America’s aging population. Unfortunately, current recruitment and retention of workers of all kinds is an ongoing challenge for a number of reasons, including inadequate funding under public programs and the physical and emotional demands of the work. While LeadingAge and its members continue efforts to improve our field’s workplace culture, changes in public policy are needed to ensure adequate numbers of well-trained and qualified caregivers now and in the future.Solutions/recommendations:Create a foreign temporary guest worker program targeted on aging services with guardrails protecting these workers from exploitation. Immigrants already make up 24% of the direct care workforce in long-term services and supports; more will be needed to provide essential care and services. We have drafted the IMAGINE initiative to remove current barriers to recruitment. Support geriatrics workforce legislation (S. 299 and H.R. 2781) that provides educational and grant opportunities and ensures an adequate supply of professionals to meet the needs of an aging population.Support the Direct CARE Opportunity Act, H.R. 4397/S. 2521, which would fund recruitment, retention, and support of direct care workers, the backbone of the long-term services and supports field.Other issues and solutions: LeadingAge was pleased to hear discussion of several measures we support, including:The Improving Access to Medicare Coverage Act, H.R. 1682. This bill would address a “surprise medical billing” issue that affects thousands of Medicare beneficiaries who are hospitalized as outpatients for “observation.” Beneficiaries in this situation later find that Medicare will not cover any post-acute care they may need because they do not meet the three-day stay requirement. Rep. Courtney’s bill would count all time a beneficiary spends in the hospital, whether as an outpatient or inpatient, toward the three-day stay requirement. This measure has bipartisan cosponsorship totaling 58 House members.The Nursing Home Workforce Quality Act, H.R. 4468. This legislation would correct the counterproductive provision of the Nursing Home Reform Act of 1987 that removes a nursing home’s authority to train staff if the nursing home has been assessed fines above a certain level on its annual state survey. The loss of nurse aide training authority serves no useful purpose and in fact is an obstacle to quality improvement for nursing homes that need to increase their staffing levels. The prohibition exacerbates the severe workforce shortage in long-term care and is especially harmful in rural areas where there often are no alternative training sites. The prohibition on nurse aide training lasts for a mandatory two-year period. The Nursing Home Workforce Quality Act would restore a nursing home’s authority to train staff as soon as the nursing home comes back into compliance with all federal regulations. The Home Health Payment Innovation Act, H.R. 2573. This measure would require Medicare payments to home health care providers to be based on evidence and not assumptions about potential negative behavior. Last year, the Bipartisan Budget Act of 2018 made significant changes to the Medicare home health payment system, including a budget-neutral transition to a 30-day unit of service beginning on January 1, 2020. Under this law, Medicare rates to home health providers under the Patient-Driven Groupings Model (PDGM) will be reduced by 6.42%. In implementing the new law, the Centers for Medicare and Medicaid Services (CMS) built an assumption into payment rates that home health agencies will change documentation and coding practices under PDGM to maximize Medicare reimbursement. The 2020 Medicare payment rule will reduce payments prospectively because of the statutorily mandated assumption that providers will automatically change behaviors.The Home Health Payment Innovation Act will preserve Medicare recipients' access to home health services and provide a pathway for innovative approaches to using these services. The bipartisan legislation will prevent unwarranted payment rate cuts by basing any behavioral adjustment on actual evidence and limit the risk of disruption in care by providing a phase-in for any necessary rate increases or decreases.?Permanent 7.5% threshold for the medical expense tax deduction, H.R. 2073. Without this legislation, the threshold will return to 10% of adjusted gross income, reducing both the number of taxpayers who may use the deduction and the amounts that may be deducted. The lower threshold is especially important for older people who generally have higher medical expenses than younger populations and lower incomes. In addition, the deduction makes life plan communities more affordable for people who prepay their future health and long-term care costs as part of their entry and/or monthly fees.ConclusionLeadingAge appreciates the breadth of caregiving issues the committee explored at this hearing. These issues become ever more pressing as our older population continues to grow. We look forward to working with the committee on legislation implementing the many excellent ideas advanced at the hearing and we hope that our additional recommendations will be considered.? ................
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