Much of the feedback aimed at the Federal Government concerned the issue of reimbursement. One provider representative summed it up by saying that "You cannot separate money from care," and that Medicare and Medicaid programs have to pay reasonably for reasonable care. There has to be more emphasis on alternative care (home care, assisted living) to really decrease the financial pressure on nursing homes.
Some providers expressed concerns about some of CMS' policies on quality measures. For example, Florida has low restraint use, but high fall rates. Providers believe that CMS is not looking at how one area of care impacts another and about interdependencies like the relationship between restraint use and falls. They also described problems with CMS classifying resident-to-resident altercations and that special considerations needed to be made for special populations like dementia and head injury patients where they have no alternatives for placement.
State agency staff attempting to look at disease management outcomes and measure resource use said they wish that is was easier to access MDS data and resource use for dually eligible patients. Providers also expressed a need for the Federal Government to take a stronger role in the development of best practice recommendations. "We wish we still had AHCPR to do best practices. They were impartial and the information came from researchers and evaluators--not surveyors." Similar direction was sought on end of life care issues, unavoidable decline and the management of expectations of patients and families about realistic outcomes of nursing home care.