State, U.S. Face Off in Dispute Over Nursing Home Care : Health: California’s failure to comply with the new law could result in a loss of $1 billion in Medicaid funds. Governor has called rules costly and unnecessary.

As California and the federal government continue to battle over new nursing home regulations, the quality of life for about 100,000 elderly patients in the state hangs in the balance.

Whether the changes in care are largely “costly and unnecessary” as the governor has charged or whether they would dramatically improve the lives of patients in the state’s 1,150 nursing homes is the source of bitter debate.

Critics say the regulations would do little beyond increasing paperwork and point to a new six-page, standardized patient admission form, which they say is so complicated that the instructions on how to fill it out are 230 pages. Federal health officials counter that the changes will bring patients a better quality of life.

Gov. Pete Wilson has refused to implement the reforms, triggering an unusual administrative hearing in San Francisco set for today that will determine whether California has failed to comply with the new federal law and should be sanctioned with loss of up to $1 billion in matching federal Medicaid dollars.

The showdown hearing may well be postponed to allow more time to resolve the dispute outside court, according to the governor’s press secretary, Bill Livingston.

“Everybody’s suing everybody. Everybody’s a little upset about this,” said David Helmsin, program director for the California Assn. of Health Facilities, which joined with consumer groups last year in filing a class-action lawsuit against the state for failing to comply with the reforms.

The cost to taxpayers of the reforms is central to the debate. Federal, state and industry officials all agree that the law will raise the cost of patient care, but they disagree on how much.

The nursing home industry argues that the reforms will add more than $440 million to the state’s Medicaid bill. State health officials assert that the regulations would cost about $27 million, with that cost doubling if controversial “interpretive guidelines” are followed. Federal officials have declined to put a price tag on the changes.

U.S. District Judge Edward J. Garcia last month issued a preliminary injunction ordering state health officials to comply with the new regulations, which he characterized as making “not insignificant” changes in California nursing homes. California laws, he wrote, “are in many instances . . . less stringent than the requirements of the reform law.”

State officials have refused to implement the reforms and have challenged their legality in a lawsuit.

The federal regulations set forth a fundamental new approach to quality of care, beginning the moment the patient enters a nursing home. They mandate a novel method of evaluating the conditions of new patients and specify that nursing homes must have sufficient staff to ensure that patients receive all therapy and attention to enable them to function at their highest possible level, mentally and physically. Those who are capable of walking and bathing themselves, for example, must be given an exercise program to help keep up their skills and develop new ones, if possible.

The law sets forth new curbs on the use of physical restraints and drug therapy. It also gives new rights to patients to object to transfers and to choose their personal attending physician.

“I don’t object to (the new law) or anything that improves patient care,” said Vicki Hyde, a nurse at Las Flores Convalescent Hospital in Gardena. “But it’s going to take a lot of time and money to implement these things that we just don’t have right now.”

Some of the changes, she added, will result in little or no benefit to patients.

She pointed to a new standardized “resident assessment form” that must be filled out within seven days of a patient’s admission to a nursing home. This form would replace one that California nursing homes now use to gather much of the same information.

The old form relied on staff to fill out a simple checklist and present a cogent narrative.

The new, six-page form is much more complicated. The instruction manual accompanying the form is 90 pages. The federal guidelines telling the state how to use the form is 140 pages.

Hyde said the form is so confusing that she attended an all-day seminar devoted to explaining to nursing home staff how to navigate through a maze of multiple-choice questions that relies on a confusing new jargon of acronyms. Hundreds of boxes must be checked or filled in with a special symbolic code that includes tiny dots and triangles.

Judy Eighmy, a San Diego nurse who has taught such seminars, said that when people first see the form, it sets off a “wave of murmurs” through the room. “The first thing they say is, ‘Oh, no!’ ”

After explaining it three or four times, she said people begin to catch on.

“The sequence of it is a little awkward. . . . It doesn’t flow the way a nurse would do an assessment. That’s part of the problem, along with the size of the print. People have trouble just reading the print” because it is as small and crowded as the printing in the classified advertising section of a newspaper.

In the long run, Eighmy said, the form will lead to a more comprehensive assessment of patient care. She estimated that it will take twice as long to fill out the new form--a total of about an hour and a half.

Helmsin, at the California Assn. of Health Facilities, said: “I’m told in practical terms it’s taking from one to five hours per patient.” Assuming it took one extra hour, Helmsin estimated the overall cost to the Medicaid program would be $8 million.

One of the fears in the industry, Helmsin said, is that nursing homes will not be properly funded to hire additional personnel to help with the forms and that nurses--who are in short supply--will have to be diverted from patient care to paperwork.

John Rodriguez, deputy director of medical care services for the state Department of Health Services, said that he is certain it will not cost millions of dollars for nursing home operators to use the new federal form. “That’s a gross exaggeration of (the money) they need,” he said.

He criticized the new form as being of “marginal” value in California because the old one was already comprehensive. He said the new form exemplifies how the federal nursing home reform focuses more on procedural changes than patient care.

The form was developed at a cost of about $6 million by the U.S. Health and Finance Administration and private consultants.

Federal health officials were not available for comment on the form. Nursing industry officials pointed out some of its advantages. They said patient assessments will become a uniform process at nursing homes across the country. The unique format of the new form is ideally suited to computerized analysis. This could assist researchers in studying and categorizing patients based on their needs and be used as a means of figuring federal reimbursement levels, Eighmy said.

By far the greatest expense of the new reforms will stem from the requirement that nursing homes maintain patients at the highest level of functioning.

“This is the single largest cost factor,” Helmsin said. The industry has estimated that it will add more than $300 million to nursing home expenses. To ensure that patients get all the physical therapy, restorative work and stimulation necessary to help them maintain their highest level of functioning will require additional funding to hire more hands-on care-givers, Helmsin said.

“The intent is to create less use of restraints and more patient independence,” he said. “That’s an excellent idea but if you don’t use postural supports and bedrails then you have to supplement the staff with more people and care-givers who are going to have to be with that patient much more frequently.”

Dennis Eckhart, supervising deputy attorney general representing state health officials, said: “There’s still a tremendous dispute about the cost.” Several months ago, Rodriguez agreed in a deposition that the cost to implement the new reforms would amount to about $400 million, but now he says his estimate was based on the “worst-case scenario” and that he lacked complete, accurate information.

“The initial estimates by the state were off. The information we have is that some states are spending just a few cents more per patient per day to implement the (law) while others are spending several dollars. Not all states are implementing all the regulations in the same way.”

The state Medicaid program--known as Medi-Cal in California--pays $65 a day per patient to provide nursing home care.

“You can aspire to any kind of care you like but if you only get $65 a day, that’s all you can give,” Helmsin said. “The theme throughout this dispute has been one of money.”