HB 1993 Questions:

#a.  The availability of alternative housing and care settings for the elderly, including the use of rent-subsidized facilities, assisted living facilities, and adult family care homes.
#b. The availability of community-based care arrangements that support elderly individuals to age in place in their own homes and in alternative housing and care settings.
#c. The role of family members in caring for elderly relatives and ways in which quality family care can be encouraged.
#f. The role of the certificate of need process in the development of systems of long-term care for the elderly.
#n. The ways in which other states have promoted the development of alternative and home-based care and what they have learned from these innovations.

Investigators: Larry Polivka, Jennifer Salmon, Sandra Reynolds, Stephen Golant, D. Helen Moore, and Mary Kaplan

Underlying research questions:

1. What is the full array of publicly-funded home and community-residential options available in Florida?
2. What are the eligibility requirements for these programs? 
3. What is the profile of the consumers in each of the programs?
4. How does access to these programs vary from county to county; region to region; rural to urban areas?
5. Are there differences in utilization based on race and ethnicity?
6. How does access vary between the young (under 60) and old (over 60) disabled?
7. What are the costs for these programs to the State?
8. What are the costs for these programs for elders?
9. What is the level of unmet need?
10. What is the state of waiting lists for these programs?
11. What is the State and Federal legislation that affects the availability of these programs?
12. What are other states doing to balance their long-term care system so that public funding provides care in home and also community-residential settings such as HUD-supported housing, assisted living facilities, and adult family care homes?
13. What are the advantages of disadvantages of the three most common HCBS models: agency-directed, consumer-directed, and managed care (PACE or SHMO).
14. What changes in Florida’s legislation would be needed to increase availability of these home and community based programs?
15. How can the certificate of need process be used to increase or decrease program availability across the spectrum of care and throughout the entire state?
16. What could be the unintended consequences of increasing the number of frail elders at home or in community-residential settings? How well can we guarantee the appropriate level of care? How will it impact the current, mostly institutional, long-term care system in the state (i.e., will nursing homes have much frailer residents who need a more costly level of care?).
17. What is the percentage of elderly being cared for by family caregivers?
18. What is the estimated value of informal caregiving?
19. What is the profile of the family members who care for elderly relatives?
20. What is the physical and emotional impact of caring for an elderly relative on family members?
21. What interventions can have a major impact on the quality of care provided by family  caregivers, as well as the reduction of stress and burden in caregivers and the amount of time that they can provide care.
22. What is the experience of family caregivers in providing care? Are there differences due to the relationship between caregivers and family members (e.g. spouse, adult child, friend, or neighbor)?
23. What type of support do family caregivers need to do their job effectively?

Approach:

1. Develop a model for forecasting the need for long-term care in Florida.  Using national and state population data that estimate level of functional impairment, availability of informal caregivers, and other factors (morbidity and mortality), develop a profile of Florida’s long-term care consumer for 2000-2025.  Use a model developed by Alan Ackman for the 1995 Commission on Long-Term Care and update it using data that were not available then (AHEAD Waves 1 and 2; the AHCA/DOEA Profiles Database; etc.).

2. Work with AHCA, Department of Elder Affairs, Area Agencies on Aging, and Department of Community Affairs staff to develop a catalog of HCBS and community-residential programs in place in at least one geographic region of the state (including demonstration projects).  This would include: CCE, HCE, HCBS Medicaid Waiver, HCBS Medicaid HMO, Alzheimer’s Disease Initiative, Channeling Project, Cash & Counseling Demonstration Project, OSS, ALE Waiver, Medicaid HMO Waiver in ALF, PACE, and Service Coordinators in HUD-financed housing.  Describe the state and federal legislation that establishes each program and how it affects access to these options.  Describe the eligibility requirements and per client costs for each program.  Compare program access by young vs. older disabled individuals.

3. Update the Counties Database (a FPECA database of county level data that addresses supply and demand factors in long-term care) to include 1999/2000 data and one year of HUD housing data from the CASERA project.  Conduct a longitudinal analysis (1996, 1998, and 2000) of some of these factors to understand if they were affected by policy changes (e.g. the Balanced Budget Amendment, changes in payments to nursing homes, and funding patterns for HCBS and ALF).  Address how programs vary around the state by county, region, and rurality.  In addition, address the changes in waiting lists from 1996 to 2000.

4. Using three FPECA databases: Commission on Long-Term Care Project II Database (1995 statewide representative sample of long-term care clients), the Robert Wood Johnson Foundation funded Consumer Choice Project (1999 representative sample in two counties), and the AHCA/DOEA Profile Database (1998? data for the state), understand the predictors of being in a particular program.  Are they based on need, geography, race/ethnicity, availability of a caregiver, or other factors?  What is the level of frailty in these programs?  What is the level of unmet need even among individuals who are receiving care? Using the AHEAD database, address the level of unmet need in the general population.

5. Synthesize the research literature available from California, Oregon, Washington, Michigan, and other states that have substantially increased their public support for home and community based long-term care.  What has been the overall experience across states?  What are the strengths and weaknesses of agency-directed, consumer-directed, and managed care models? What are the lessons learned?  How do states manage the “woodwork effect.”  What have been the unintended benefits and consequences of the policy changes?

6. Conduct a review of literature on family care giving, using relevant databases (Age line, Medline, PsychLit, etc.). This would include information on caregivers with special needs, such as minority caregivers, caregivers who are employed, and those who provide care for persons  who have Alzheimer’s disease or who are developmentally disabled.

7. Utilize existing state databases (Department of Elder Affairs, Area Agencies on Aging,  Alzheimer’s Association Florida Initiative, etc.) to establish a profile of Florida’s family caregivers, their needs, and barriers to services.

8. Obtain information on existing caregiver programs and interventions in Florida and in other  states through Area Agencies on Aging, Florida Department of Elder Affairs, Robert Wood Johnson, the Alzheimer’s Association, and other federal and state programs. Legislation and policies affecting caregivers in Florida and in other states will also be reviewed and summarized.

9. Conduct focus groups with small groups (8-10) of family caregivers based on diagnostic category of the care recipient (Alzheimer’s or stroke), site of caregiving (at home or in a congregate setting), and caregiver relationship to care recipient (spouse, adult child, etc.).  Themes to be addressed in focus groups include: the experience of providing quality care at home; support needed by caregivers; differences in needs due to the disease, the site of care, or the care giving relationship.  Transcribe focus groups and conduct qualitative analyses of the transcript data.
 
 

HB 1993 Questions:

#d. The adequacy of reimbursements for the cost of providing care to the elderly in nursing homes and in alternative housing and care settings.
#e. What is the availability and affordability of long-term care insurance coverage and the potential for funding long-term care through such coverage?
#m. The additional costs to Medicaid, Medicare, and the family when a patient suffering from a preventable condition has to be admitted to a hospital.
#l. The primary causes for recent bankruptcies facing the nursing home industry.

Investigators: Paul Duncan, Sue Reynolds-Scanlon, Hongbin Chen, and Glenn Mitchell

Underlying Research Questions:

Reimbursement Rates and Bankruptcy
1. What are the current rates of reimbursement by payer for: nursing home, assisted living facility, and home care services?
2. What is the recent history of these rates?  When were they last reviewed? Adjusted?
3. What is the observable impact to date of federal legislative/regulatory actions, particularly the Balanced Budget Amendments for nursing homes and Medicaid Waiver rules for assisted living facilities and home care, and the subsequent adjustments?
4. What is known about the current costs of providing nursing home, assisted living facility, and home care services? 
5. Is it possible to measure the “true costs” associated with units of care?
6. To what extent is it desirable and appropriate for reimbursement rates to vary as a reflection of variation in costs by location?
7. To what extent is nursing home bankruptcy due to market factors (e.g., referrals to home or assisted living facilities), business factors (e.g. management issues), or quality of care factors?  Is there a relationship among these factors?
8. How many nursing homes in Florida are within a formal bankruptcy process; how many are in serious financial jeopardy (and what percentage of the industry do these categories represent)?  Where are these facilities located and what percentage of the beds do these facilities represent in those areas?
9. What are the primary causes of financial instability in these specific instances? Is the situation improving or worsening in these cases?
10. How many of the financially threatened facilities are in danger of actually closing (with no buyers to continue the operation under new ownership)? 
11. What are the facts about recent bankruptcy experiences in the nursing home industry in Florida and elsewhere?  How many bankruptcies  have occurred?  Are there observable patterns in the location, size, ownership, mission, or other attributes of nursing homes or nursing home companies that have experienced bankruptcies?  What is the process by which an organization moves from initial indications of financial distress to the various steps in the bankruptcy process? 
12. How have bankruptcies (and other aspects of financial distress) affected the availability and delivery of services?  How many and which nursing homes have closed? How many beds have been closed?
13. What are the “causes” of the observed bankruptcies from the perspectives of the owners? The claimants/creditors? The courts? The licensure or other relevant regulatory agencies? 

Long-Term Care Insurance
1. How is the current atmosphere of consolidation within the insurance industry into only a few suppliers of long-term care insurance going to affect the costs and standardization of the product offered to the public? 
2. Within the insurance industry, how are companies attacking problems with underwriting such insurance, and is current national legislation going to help the reliability of the market?
3. What are the current numbers (nationally) of individuals holding long-term care insurance coverage by age group?
4. What type of education effort needs to be initiated to educate the younger public of the need for being informed on long-term care issues and risks, and which groups should participate in dissemination efforts?
5. How are potential consumers and their advocates to make informed choices of long-term care insurance policies with the market in flux, and policy rates, length and type of benefits, and restrictions for the various plans changing rapidly?
6. Are state efforts and other "best practices" in developing incentives for individuals to purchase long-term care insurance having an effect?
7. Should long-term care insurance exist as a public or private component of a comprehensive approach to long-term care?
8. How are state and national efforts in development of tax credits and deductions in  promotion of long-term care insurance affecting the market for this product?
9. How have recent court cases impacted the future of long-term care and the need for  long-term care insurance?
10. What are the viewpoints of the industry, consumer advocates, and consumers themselves on the need for long-term care insurance, its affordability and benefits now and in the future? 
11. Will long-term care itself will look the same, with the appropriate services covered, when the time comes to access the policy benefits 20 years in the future?
12. How will the public's use of long-term care insurance affect anticipated public sector long-term care costs, though impact on Medicaid expenditures and other services? 
13. Is long-term care insurance the only vehicle that should be established to prepare for long-term care risks in the future?

Costs of Preventable Conditions
14. What are some of the common conditions that are regarded preventable?
15. To what extent are patients admitted to a hospital due to these conditions?
16. What are the costs of this kind of hospital stay to Medicaid, Medicare, and family?  How much more costs compared with those received at a lower level care, without compromising the quality?
17. What kind of patient/facility profile or risk factors are related to those conditions and hospitalization?
18. Is there any intervention to prevent those conditions or reduce hospitalization in order to avoid the additional costs occurred?

Approach:

1. Conduct a review of recent changes in the reimbursement policies of Medicare, Medicaid, and private insurance carriers, with particular attention on the BBA and its adjustments and recent Medicaid Waivers, and the reimbursement policy consequences thereof.
2. Conduct key informant interviews with Medicaid representatives regarding current rates and recent adjustments.
3. Conduct key informant interviews with representatives of the nursing home and assisted living facility industries in Florida regarding changes in the cost structure surrounding nursing home services.
4. Conduct a review of the health services research literature regarding nursing home, assisted living facility, and home care costs and reimbursements.
5. With S. Reynolds, conduct develop unit costs for these long-term care services to be used in a forecasting model for long-term care needs and utilization.

6. Conduct a review of public information regarding recent bankruptcies in the nursing home industry in Florida and elsewhere.
7. Conduct key informant interviews with representatives of the nursing home industry in Florida regarding bankruptcies and other examples of financial distress, including their sequelae.
8. Conduct a review of the health services research literature regarding nursing home (and nursing home ownership company) bankruptcies.
9. Using the FPECA Counties Database (with M. Oakley), conduct analyses of market factors such as comparing per capita spending on alternatives to nursing home care to spending on nursing home care and availability of alternatives and nursing home slots in each county.
10. With M. Oakley, conduct data analyses comparing nursing homes with high and low quality of care indicators (if available) and those that have gone bankrupt in the past two years.

11. Conduct analysis of policy papers and publications from the insurance industry and its associations, consumer advocacy groups, and individual accounts to uniformly present the  issues and viewpoints of all the participants in discussion of long-term care insurance as a part of the comprehensive approach to financing long-term care.
12. Conduct key informant interviews with the Florida Insurance Commissioner's Office, AARP representatives, key policy specialists nationally and within the states of Florida and New York, and other groups such as representatives from the Health Insurance Association of America (HIAA), and the Center for Long-Term Care Financing. 
13. Review pending state and national legislation that apply to long-term care insurance.

14. Conduct a review of the literature on preventable conditions (such as pressure ulcers, falls, dehydration, infections)  published during the last ten years.

15. Depending on the available data, focus on several physical conditions deemed “preventable.” Discuss the potential risk factors of these conditions and define the study populations.
16. Extract the results from the literature concerning the hospital costs to Medicaid, Medicare, and the family due (where available) from these preventable conditions.  Also highlight the difference of costs between the hospital and nursing home stay.
17. Find any intervention done in this field either on an individual level or facility level to reduce hospitalization, by maintaining patient care at nursing homes or community, and thus reducing costs.
 
 

HB 1993 Questions:

#g. The extent to which the quality of care in long-term care facilities in this state is compromised because of market changes that affect the financial stability of the long-term care industry.
#o. The difference between the quality of care provided by for-profit skilled nursing facilities and by not-for-profit skilled nursing facilities.
#p. An evaluation of how the quality of care in the long-term care facilities of this state compare with the quality of care in such facilities in other states.

Investigators: Kathryn Hyer, Chris Johnson, and Elaine Richard

Underlying research questions:

1. What are quality of care indicators that can be defended by clinical research?
2. How does quality of care vary between Florida and other States?  What are the differences in the nursing home market or quality assurance that might explain these differences?
3. How does the quality of care vary between for-profit vs. not-for-profit nursing homes in Florida?

Approach:

1. Conduct a review of the clinical and nursing home literature to develop a list of key indicators of quality of care that can reliably distinguish between poor and good quality nursing homes (e.g. JAHCO, HEDIS, OSCAR, MDS). 
2. Gather examples of state nursing home quality assurance programs (e.g. the Gold Seal and Quality Monitor programs in Florida) and review them for adequacy of measuring quality, given the results of the first literature review.
3. If available, identify databases that provide data on these key indicators for nursing homes in Florida and other states. 
4. Conduct data analyses that compare for-profit and not-for-profit nursing homes in Florida using these quality indicators.
5. Conduct data analyses that compare nursing homes in Florida and other states using these quality indicators.
6. If data are not available, conduct a policy literature review that compares the overall quality of nursing home care in Florida and other states and between not-for-profits and for-profits by researchers such as Catherine Hawes and Charlene Harrington.
 
 

HB 1993 Questions:

#h. The effect of lawsuits against nursing homes and long-term care facilities on the cost of nursing home care and on the financial stability of nursing home industry in the state.
#i. The kinds of incidents that lead to the filing of lawsuits and the extent to which frivolous lawsuits are filed.
#j. The cost of liability insurance coverage for long-term care providers and the extent to which such costs affect the affordability of care.
#k. The availability of liability insurance coverage for long-term care providers through Florida’s insurance companies.

Investigators: Mary L. Oakley, Chris Johnson, Ph.D. and TBA Legal Scholar

Underlying research questions:

1. What percentage of Florida’s nursing home industry has experienced one or more lawsuits in the past few years (with trends)? (Obtain estimate regarding assisted living facilities in Florida.)
2. How does this compare with nursing home industries in other states? 
3. What is the prevalence of multiple lawsuits filed against individual facilities in Florida (with trends)?
4. What is the current average cost per suit (with ranges)?
5. What are the component costs and who (typically) pays them directly? For example, how much for legal defense, staff time, settlement costs?
6. In what ways has the industry responded/adapted to the increase in lawsuits (consider new position categories, staff training, other developments)?
7. Does the liability climate have an impact on the industry’s ability to recruit and retain staff?
8. Has legal action been the main contributing factor in one or more cases of nursing home bankruptcy in Florida? If so, explain. If not, what are the main causes of bankruptcies?
9. What percentage of all lawsuits filed are brought for “frivolous” or minor incidents?  (Based on a review of all lawsuits filed in one or more District Court areas during a limited time period, using an operational definition of frivolous or minor incident, implying the absence of actual harm or damages.)
10. For what reasons are the majority of lawsuits filed? How can suits be categorized, and what percentage of all suits fall into each category? (Consider also the percentage that could be classified as medical malpractice.)
11. What is the percentage of suits settled out of court instead of tried and how does this compare with liability suits against other industries in Florida? (Also, are suits ever dropped or withdrawn?)
12. What percentage goes before an arbitrator or a mediator, with what result? 
13. On what basis do medical experts (geriatric physicians and nurse practitioners) determine whether adverse clinical outcomes were avoidable or unavoidable? What criteria do the state surveyors apply? Do these clinical decision rules typically apply in the legal proceedings against nursing homes? 
14. What is the current average cost of liability insurance coverage per nursing home bed in Florida (with range)?
15. How does this compare with the cost of coverage in other states?
16. What percentage of the insurance companies operating in the voluntary market has increased their premiums recently, and by how much?
17. Do insurance companies adjust rates selectively, according to risk assessment criteria, or change rates for all facilities insured?
18. Have assisted living facilities in Florida experienced trends similar to the nursing home industry regarding the cost of liability insurance?
19. To what extent does a switch to “surplus lines” for liability coverage account for reported marked increases in premiums? How do premiums compare, on the average, between those charged by voluntary and surplus lines insurance carriers?
20. How are nursing homes and ALFs absorbing or accommodating the increasing cost of premiums? Does the ability to absorb the cost differ for independent, not-for-profit, and for-profit, multi-facility companies?
21. Are facilities able to pass the increase in costs for liability coverage to the consumer or third party payer? If  yes, how and to whom?  If  not, why not? 
22. What is the number of insurance companies in the voluntary market that are renewing  policies and writing new policies for nursing homes and ALFs in Florida?
23. How many insurance companies have decided to withdraw from the Florida market (with detail, e.g. is it a selective or total withdrawal; is the withdrawal confined to Florida; is it a decision to accept no new business while renewing existing policies, etc.)?
24. What is the percentage of the nursing home industry covered by a surplus lines insurer (that is not regulated by Florida’s Department of Insurance)? 
25. What percentage of the nursing home industry is self-insured? How many facilities now have no insurance?
26. Are Florida’s assisted living facilities experiencing difficulty in obtaining liability insurance similar to the experience of the nursing home industry?
27. What is the loss ratio of insurance companies covering the nursing home industry in Florida?
28. Has the scope of coverage available changed: have standard policy deductibles increased or policy limits decreased?

Approach:

1. Analyze (quantify and categorize) all lawsuits filed against nursing homes in the region during a specified time frame using an automated court docketing system (database) in at least one major metropolitan area of Florida (likely to be the Tampa Bay area and Broward County). 

2. Collect information from Florida’s Department of Insurance: their analysis of survey data from their study of the insurance companies that have written liability insurance for Florida long-term care facilities.

3. Obtain information from the Agency for Health Care Administration regarding the financial status of nursing homes in Florida.

4. Obtain data directly from the multi-facility nursing home and assisted living companies regarding insurance coverage and costs; lawsuit activity, correlates, costs and impact. Work with associations to obtain similar information regarding non-profit and independent facilities. 

5. Key informant interviews not limited to plaintiff attorneys; defense attorneys; mediators; state surveyor supervisors; insurance agents/brokers; accounting firms; health care facility corporate officers; nursing home administrators; directors of nursing; medical directors and attending physicians. Use of case studies will be considered.

6. Review information on state laws regarding nursing home residents’ rights and compare state statutes.