MINORITY STAFF
COMMITTEE ON GOVERNMENT REFORM
U.S. HOUSE OF REPRESENTATIVES
NOVEMBER 2005
Summary
The Nursing Home Staffing Act of 2005
BACKGROUND
Numerous studies have found that the 17,000 nursing homes in this country are severely understaffed. In March 2002, researchers at the Department of Health and Human Services (HHS) concluded that 90% of nursing homes have staffing levels that are too low to provide quality care. The researchers identified specific minimum staffing levels that would improve thecare received by nursing home residents. However, these staffing levels have not been implemented. In order to ensure that this important research is not ignored, the Nursing Home Staffing Act of 2005 would establish the minimum nurse staffing levels identified by HHS researchers.
MANDATORY NURSE STAFFING LEVELS
The bill requires that nursing homes comply with HHS-identified staffing levels for registered nurses, licensed nurses, and certified nurse aides. These staffing levels would require that all nursing home residents receive at least 4.1 hours of nursing care each day. Under the bill, these
staffing levels must be achieved within two years after the date of enactment, except that if the HHS Secretary determines that a two-year implementation period is not feasible, he can delay implementation until five years after the date of enactment.
INCREASED FUNDING
The bill increases resources to nursing homes to comply with these staffing levels. The bill reinstates the “Boren Amendment,” which, until its repeal by Congress in 1997, guaranteed “reasonable and adequate” Medicaid reimbursements for providing quality care. The bill also
helps fund the additional staffing by increasing the federal Medicaid match to states for payment of health care services by 1.5%.

FINANCIALACCOUNTABILITY
In order to ensure that the increased federal resources are being used to hire additional nursing staff, the bill authorizes state inspectors to examine the financial records of nursing homes.
ORGANIZATIONAL SUPPORT
The bill has been endorsed by the following groups: the National Coalition for Nursing Home Reform, the American Nurses Association, the Service Employees International Union, and the Alliance for Retired Americans.

High court hears Medicaid dispute
Counties sue state over how the cost is shared

By DANIEL BARRICK Monitor staff
________________________________________
November 13, 2008 - 12:00 am

In a case that both sides say could have a big impact on taxpayers, the Supreme Court heard arguments yesterday in a lawsuit brought against the state by the New Hampshire Association of Counties over the way Medicaid bills are shared.
The state’s 10 counties sued the state over a 2007 law that required county governments to cover what had previously been the state’s share of Medicaid expenses for nursing home and home-based-care patients. Previously, the state and counties split evenly the 50 percent of Medicaid costs that are not covered by the federal government.
A change in the law last year requires the individual counties to cover all of those nonfederal costs; in exchange, the state agreed to cover the counties’ share of other health programs. Proponents of the deal say it simplified what had been a burdensome and complicated administrative system.
But representatives for the counties say they’re getting the worse end of the deal, since Medicaid and nursing home expenses are expected to increase far more in coming years than other health programs. The counties also argue that the shift in responsibilities was forced on them by lawmakers looking to cut their expenses - and that will mean big increases in county taxes in the near future.
“The question is, who gets to decide whether local property taxes should be used to fund state-mandated programs?” Robert Dunn, a lawyer representing the New Hampshire Association of Counties, told the justices yesterday.
The details of the case may seem obscure and technical, but the underlying questions are important, reflecting both the challenges posed by New Hampshire’s aging population and the ongoing tension between the state and smaller municipalities over what the state’s financial responsibilities are.
Demographers say New Hampshire’s population is aging at a rapid rate that will put increasing pressure on the state’s health care costs, especially programs such as Medicaid, which provides health coverage for many elderly and disabled residents.
The case also reflects long-standing fights between state and local officials over issues such as education funding and health care. Cities, towns and school districts say state officials are increasingly “downshifting” their share of those expenses to the smaller municipalities.
Those municipalities, in turn, have no way to cover those additional costs other than increasing local property taxes.
“That’s the reason we’re nearly in a local taxpayer revolt,” said Ted Comstock, executive director of the New Hampshire School Boards Association.
The counties say the new Medicaid arrangement is a violation of the state constitution’s provision against unfunded mandates. That provision forbids the state from assigning additional costs to municipalities without the consent of that local body.
Andrew Livernois, the lawyer representing the state before the Supreme Court yesterday, told the justices that the new Medicaid arrangement was not an unfunded mandate since the counties have paid a portion of Medicaid costs for several years - the change simply increased the counties’ share.
“The increase of the dollar amount alone does not constitute a new responsibility,” Livernois said.
Sen. Kathleen Sgambati, a Tilton Democrat who helped write last year’s law that changed the Medicaid sharing arrangement, said the Legislature added a provision to cap the counties’ expenses at their current level for the first two years.
“The intent was to ensure the counties that this was not a cost shift,” Sgambati said yesterday. “The state assumes all the risk in this situation.”

If the justices rule in favor of the counties and determine the new sharing system to be unconstitutional, Sgambati said, it could add millions of dollars in expenses to the state budget over the next two years.
Earlier this year, a Merrimack County Superior Court judge ruled against the counties, saying the new Medicaid arrangement was not an unfunded mandate, because the counties had not yet seen any additional costs. Judge Carol Ann Conboy did say the counties could renew their claim in a few years if they did see Medicaid costs increase.
But Supreme Court justices appeared skeptical of the state’s case yesterday, repeatedly questioning claims that the change in Medicaid obligations was not an expansion of the counties’ financial burden.
“This is all about dollars and cents,” said Justice James Duggan. “It’s all about someone being forced to pay something.”

PURPOSE OF THE HCBS WAIVER PROGRAM

The Medicaid Home and Community-Based Services (HCBS) waiver program is authorized in §1915(c) of the Social Security Act. The program permits a State to furnish an array of home and community-based
services that assist Medicaid beneficiaries to live in the community and avoid institutionalization. The State has broad discretion to design its waiver program to address the needs of the waiver’s target population. Waiver services complement and/or supplement the services that are available to participants through the Medicaid State plan and other federal, state and local public programs as well as the supports that families and communities provide.

The Centers for Medicare & Medicaid Services (CMS) recognizes that the design and operational features of a waiver program will vary depending on the specific needs of the target population, the resources available to the State, service delivery system structure, State goals and objectives, and other factors. A State has the latitude to design a waiver program that is cost-effective and employs a variety of service delivery approaches, including participant direction of services.

The waiver application is based on the HCBS Quality Framework. The Framework focuses on seven broad, participant-centered desired outcomes for the delivery of waiver services, including assuring participant health and welfare:
• Participant Access: Individuals have access to home and community-based services and supports in their communities.
• Participant-Centered Service Planning and Delivery: Services and supports are planned and effectively implemented in accordance with each participant’s unique needs, expressed preferences and decisions concerning his/her life in the community.
• Provider Capacity and Capabilities: There are sufficient HCBS providers and they possess and demonstrate the capability to effectively serve participants.
• Participant Safeguards: Participants are safe and secure in their homes and communities, taking into account their informed and expressed choices.
• Participant Rights and Responsibilities: Participants receive support to exercise their rights and in accepting personal responsibilities.
• Participant Outcomes and Satisfaction: Participants are satisfied with their services and achieve desired outcomes.
• System Performance: The system supports participants efficiently and effectively and constantly strives to improve quality.

For More Information Regarding the HCBS Waiver please see:
http://www.dhs.state.mn.us/main/groups/aging/documents/pub/dhs16_143051.pdf

Exposure to Antipsychotics and Risk for Stroke
Use of antipsychotics, especially atypical drugs, raises risk for stroke, and this risk is higher in patients with dementia than in those without.
During 2002, analysis of clinical trial data raised concerns that exposure to the atypical antipsychotic drug risperidone led to excess stroke risk in dementia patients. However, whether stroke risk associated with antipsychotic drug exposure differs among people with or without dementia is unknown. Using a large database that predated these concerns, U.K. investigators compared stroke incidence during periods of exposure and nonexposure to antipsychotic drugs within individual patients who had or did not have dementia.
Of 6790 patients who had first strokes and were prescribed antipsychotic drugs between 1988 and 2002, 6334 were prescribed at least one typical drug (most commonly phenothiazines), and 905 patients were prescribed at least one atypical drug (most commonly risperidone). The median age at first exposure to any antipsychotic drug was 80, and the median age at first stroke was 81. Exposure to any antipsychotic drug was associated with significantly higher risk for stroke (rate ratio, 1.73); excess risk was noted for both typical drugs (RR, 1.69) and atypical drugs (RR, 2.32). In patients with dementia, exposure to any antipsychotic drug was associated with a rate ratio for stroke of 3.50, whereas, in patients without dementia, the rate ratio was 1.41. In all analyzed groups, the rate ratios decreased towards 1.0 during the 5 months after treatment ended.
Comment: Exposure to antipsychotic drugs is associated with excess risk for stroke, and this risk appears to be higher among patients with dementia than among those without dementia. Notably, the mechanism by which these drugs raise stroke risk is unclear. Nevertheless, these results should serve as yet another red flag for clinicians, joining those of recent studies that showed minimal efficacy in patients with dementia who received antipsychotic drugs (JW Dec 28 2006).
— Paul S. Mueller, MD, MPH, FACP
Published in Journal Watch General Medicine September 11, 2008
Citation(s):
Douglas IJ and Smeeth L. Exposure to antipsychotics and risk of stroke: Self controlled case series study. BMJ 2008 Aug 28; 337:a1227. (http://dx.doi.org/10.1136/bmj.a1227)