The Joint Commission on Health Care met on December 7 to consider policy options presented by staff as a result of the three studies directed by the Commission this year. The Commission also approved a plan for staff studies in the upcoming year; planned study topics include local health department structure and financing, ways to reduce unnecessary emergency department utilization, the affordability of assisted living facilities, and ways to enhance provider data sharing to improve quality of care.
The Commission had previously received staff reports on the three studies undertaken this year, each of which included a series of policy proposals. A summary of each study and the recommendations adopted by the Commission follows below.
Strategies to support aging Virginians in their communities: This study examined the services necessary to support aging in place and potential gaps in availability of these services, as well as the coordination of state and local programs. Staff found that an increasing number of older residents require services to remain in the community, with home care and affordable housing the largest unmet needs, and offered a series of recommendations for enhancing Virginia’s support for community-based care. The Commission approved the following recommendations:
- Direct the Department of Medical Assistance Services (DMAS) to develop a plan to amend Virginia’s Medicaid program to offer a home- and community-based services option with criteria that are less stringent than current eligibility requirements for the home- and community-based services waiver. The plan would specify the eligibility criteria and services offered.
- Direct the Department of Aging and Rehabilitative Services to estimate the amount of additional state funding required to address the current unmet need for home care and home modification services.
- Provide a tax credit to eligible family caregivers to offset the cost of caregiving expenses.
- Direct the Department of Housing and Community Development to target older Virginians in its housing efforts and to develop proposals for increasing the supply of permanent supportive housing for older Virginians.
Workforce challenges in Virginia’s nursing homes: This study was charged with an examination of workforce shortages in nursing facilities and an analysis of how staffing and quality could be improved. The issue of staffing standards in nursing homes has been debated at the General Assembly for many years, and generated the most discussion in the Commission’s consideration of the staff report. Staff found that nursing homes across the Commonwealth experience difficulties with staff recruitment and retention, and that 21 percent of facilities do not provide enough hours of direct nursing care relative to the expected hours calculated by the Centers for Medicare and Medicaid Services (CMS). Nursing homes with lower staffing are more likely to receive lower ratings from CMS on health inspection criteria. The report points out that nursing homes that serve a higher proportion of Medicaid recipients have lower staffing levels on average; typically, facilities offset lower reimbursements from Medicaid with the higher rates paid by Medicare and private-pay residents, and facilities serving large numbers of Medicaid payments are limited in their ability to raise revenues to fund additional staffing. The Commission approved the following recommendations:
- Direct DMAS to develop a plan to increase Medicaid reimbursement rates for nursing homes with a disproportionate share of Medicaid-funded residents.
- Implement a staffing standard based on resident acuity (each nursing home would be required to provide the number of expected total direct care hours and total registered nursing hours that are calculated by CMS, with compliance determined by the Virginia Department of Health on a quarterly basis).
- Provide a general fund appropriation to the Long-Term Facility Nursing Scholarship program, which was established in 2016 but not funded. The program offers scholarships contingent on a commitment to work in a Virginia nursing facility.
- Direct DMAS to design and seek CMS approval for a quality improvement program for nursing homes, to be funded with penalties collected for federal violations or non-compliance.
- Direct DMAS to include a formal evaluation of the proposed Value-Based Purchasing program’s effectiveness at increasing staffing and quality as part of the development of the program. In 2021, the legislature directed DMAS to develop a Value-Based Purchasing program; the program is currently being designed and is scheduled to begin implementation in July 2022. The staff report noted, “Pay-for-performance initiatives are highly variable and need to be designed and implemented effectively to improve nursing home quality,” suggesting the inclusion of a formal evaluation to assess effectiveness as part of the program’s design.
- Direct DMAS to develop a plan for an enhanced reimbursement rate for nursing homes for residents with behavioral health diagnoses. The staff report noted that nursing homes are serving larger numbers of residents with behavioral health needs, who often require more staff time.
- Endorse a request from the Virginia Community College System to increase the capacity of nursing education programs.
Health insurance affordability in the individual market: Commission staff were directed to review activities in other states to address health insurance affordability in the individual marketplace, identify options to make health insurance coverage more affordable and accessible to Virginians, and estimate the impact of these options on costs and the number of uninsured Virginians. The report outlined challenges experienced by Virginians in recent years, as a lack of competition in some localities, federal actions and political uncertainty surrounding federal assistance with premium costs, and adverse selection (the withdrawal of healthier individuals from the marketplace, leaving those individuals who are more expensive to insure) resulted in increasing premiums. Staff recommended additional outreach efforts, as a large number of uninsured adults in Virginia are unaware of potential coverage options, but also noted that the effect of federal initiatives to reduce premium costs far outweighs the impact of state initiatives. Recommendations approved by the Commission include the following:
- Appropriate $3.7 million in General Funds to the state-based exchange to develop a annual marketing program, and direct the exchange administrator to prepare an annual marketing plan for outreach.
- Eliminate the tobacco surcharge on insurance plans. The report found that this surcharge, which is intended to encourage enrollment in tobacco cessation programs, is not effective in discouraging smoking, but does increase premiums and may discourage enrollment in insurance.
- Direct Commission staff to work with the Urban Institute to model estimated costs and enrollment effects of enhancing federal cost-sharing reductions for individuals up to 250 percent of the federal poverty level. Currently, cost-sharing reductions, which help to reduce out-of-pocket costs for deductibles, co-payments, or co-insurance, apply to individuals with household income at or below 250 percent of the federal policy level.
VACo Contact: Katie Boyle