Long-Term Care - Illinois General Assembly

There was also a need to contain the rate of growth in long-term care spending. No one went
into this thinking that the state would actually reduce spending. The goal was to slow the rate of
growth.
In 1993, the state was facing a very serious budget deficit, and at the same time nursing home
spending had gone up something like 50% over the previous three years. The legislature was
just desperate to find ways to balance the budget, so this provided the opportunity for reform. A
proposal to change was presented to reduce nursing home spending by essentially tightening
medical admission criteria. This may not be the solution for Illinois, but for Maine it was
the hook that would get reform going. That was the first policy initiative.
Maine was a case mix demonstration state, so there was very good data covering many years
regarding who was in nursing homes. About 15% of people in nursing homes had no Activities
of Daily Living (ADL) needs. They didn't really need to be in nursing homes. They were
independent in their ADLs. Why were they there?
The legislature was informed there were many people in nursing homes who did not appear to
be there for any good reason. They could be served less expensively in the community. The
legislature would not ordinarily have been sympathetic to that argument, because it's a little
scary. The financial situation was such that people had to make decisions that they probably
would not have under different circumstances.
The legislature agreed to tighten medical admission criteria. They also established a
requirement that any nursing home facility project had to be Medicaid cost neutral, which meant
that any facility that wanted to add beds, or do renovations, had to prove to us that they could
do it within the money they already had. This has created a very interesting market in the sale
of Medicaid revenue streams. It's been a significant element of the state’s ability to contain that
component of the system.
In the early years, after this change was implemented, nursing homes continued to admit private
pay individuals and did not inform them that Medicaid had raised the admission threshold. This
resulted in the situation that people would go into the nursing home, spend down in three
months, and be surprised to learn that Medicaid wouldn't pay for their care, because they didn't
meet the eligibility criteria. The nursing home industry must have thought that this would create
pressure on the legislature to roll back the reforms. It actually had the opposite effect. The
legislature was so irritated, because they adopted mandatory pre-admission screening for
everyone. It never would have been enacted, if they had simply been told that it was the right
thing to do. Illinois has pre-admission screening.
Maine uses a single statewide organization to do pre-admission screening for nursing homes,
and for all of the other publicly funded long-term care programs. It's one agency. This
organization is not a provider of service. There is no conflict of interest in making placement
decisions. It also does counseling.
If you want to do long-term care reform, you can't just focus on the nursing homes. It's not fair.
If you don't focus on the whole system, you just shift your spending issues from one setting to
another. Over the course of the last ten years Maine has systematically reviewed, revised, and
restructured all of the publicly-funded home care systems to also achieve the same goals that
were implemented for institutions.
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