Assisted living quality measures at the state and federal level don’t actually measure assisted living or quality, according to a new report from national nonprofit legal advocacy organization Justice in Aging. The group is calling on federal and state governments to revise existing policies to improve assisted living quality.
Through a public records request and subsequent lawsuit to gain access to the nonpublic performance measures used to oversee Medicaid-funded assisted living communities, Justice in Aging reported finding “deep problems” in both federal and state Medicaid policies. Its report, “An Illusion of Protection: Meaningless federal ‘quality measures’ endanger assisted living residents,” was released Thursday.
The report is based on California’s performance measure data for the state’s Medicaid assisted living program, but author Eric Carlson told McKnight’s Senior Living that the issue is not confined to one state. Carlson said that the underlying problems are the same across the nation: assisted living services under the federal Medicaid program are provided through state waiver programs, with no federal assisted living quality standards for reference.
Assisted living’s safety, staffing and pricing recently were the focus of a US Senate Special Committee on Aging hearing in which congressional leaders called for a government study on industry pricing and transparency, announced a mechanism to collect consumer input and pondered federal regulation.
Both the hearing and the review were coordinated in response to recent articles in The Washington Post, which in December reported on the deaths of several residents with dementia who had eloped from communities, as well as November articles by the New York Times and KFF Health News, which reported on an industry pricing structure that adds fees on top of basic charges to cover additional services, as well as rate increases and the for-profit status of most providers.
Last month, Arizona joined a growing list of states where lawmakers are calling for more transparency from assisted living communities through legislation following local media reports questioning resident safety in the setting.
A focus on California
The 18 measures the Centers for Medicare & Medicaid Services provide to state regulators do not measure quality of care or provide consumers or regulators with actionable information, according to the report. Instead, the Justice in Aging said, they are basic “check-the-box” measures covering procedural issues in the state assisted living waivers “that seem designed to elicit 100% compliance scores.”
After reviewing the performance measures, Justice in Aging concluded that they are calculated “solely to fulfill bureaucratic requirements” and not to identify problems and improve public policy.
Carlson said that state Medicaid programs issue formal “assurances” that resident health and welfare is adequately protected. Although states must develop performance measures to monitor program performance and identify potential problems, states generally only share the collected information with the federal government, Justice in Aging said. And most of those performance measures pertain to the state’s operation of its Medicaid program, not Medicaid-funded assisted living care, according to the organization.
“It’s not measuring the care in assisted living facilities and certainly not doing anything to distinguish one facility from another — not at all,” Carlson said. “If we’re concerned about what’s going on in assisted living in California and in the assisted living waiver, these just aren’t serving any purpose. For me, I found that jarring on [its] face.”
Although he said he’s not advocating for federal assisted living standards, Carlson said that the report is a first step in advocating for change from a policy advocacy perspective.
“The first step is to say that this system — the way it’s set up at the federal level and implemented at the state level — is not doing what needs to be done,” he said.
Redesigning the system
The underlying problem, Carlson said, is that no federal assisted living standards exist, leaving the federal and state governments to pay for assisted living services with no real definition or standards for what needs to be provided. Quality measures, he added, should actually measure quality and something about assisted living that allow consumers, regulators and governments to distinguish one community from another.
“There needs to be transparency,” Carlson said.
The federal and state governments should revise their policies to improve assisted living quality, including making changes so that performance measures are useful to government officials, providers and consumers, the report concluded.
Specifically, the report called on the federal government to:
- Monitor assisted living performance in a way that allows for individual communities to be evaluated.
- Improve quality monitoring of assisted living communities, including developing and enforcing standards.
- Use performance measures to address healthcare disparities.
- Make performance measure information available to the public.
- Reorient performance measures toward actual policy improvements.
“There’s a problem here — it seems we’re spendings significant amounts of Medicaid money for assisted living services without having any functional system for monitoring the quality,” Carlson said. “I would hope that people at the federal and state level — including people that were unfamiliar with this reality — would ask for changes and make changes.”
In the meantime, Carlson said he is going to continue to demonstrate the problem and investigate more to work toward improvements at the federal and state levels.
The report comes as a proposed federal rule establishing mandatory quality measures for HCBS, among other things, is under final review by the White House Office of Management and Budget. CMS has indicated that it plans to issue a final Medicaid Access Rule by April.
When the rule was proposed in July, senior living industry advocates told McKnight’s Senior Living that the proposed quality measures had the potential to burden assisted living providers financially and administratively. The organizations made a case for additional funding to implement the measures while lobbying to keep as much related oversight as possible at the state level.
