“Evidence-based policy” is more than a buzz word.  It’s a real concept.  One where data is used to see trends and areas of risk or promise, leading to better choices.  And, hopefully, better policy.  But, evidence-based policy in the RCFE world is difficult because, frankly—there isn’t much data available for review.  One critical issue in California that would benefit from data right now is how to proceed with an aging population that needs 24/7 care and support but cannot independently afford it.   

Like other states, California’s approach to this issue has been influenced by a federal long-term care policy focused on “rebalancing”.  This means redirecting nursing home-eligible, MediCal recipients to “the least restrictive setting”, most often an RCFE.  But this approach is buckling and it could be said it’s because data isn’t driving the conversation.  Take the issues below as examples:

(1)   The real push behind the rebalancing policy has been cost-savings for MediCal.  But there is ongoing concern that payment levels are not keeping pace with actual operating costs (Hernandez M. , 2007).  How is this affecting the quality of care delivered to Medi-Cal recipients?  How is this affecting RCFE enrollment in the MediCal Assisted Living Waiver program?  I don’t think we know.

(2)   The RCFE industry has made great efforts to uphold the public image that assisted living is substantially different from nursing homes (Kane R. A., 1998) (Wiener, 2002)(Calkins, 2007).  However, with the increasing acuity of residents, assisted living regulations now allow more frail and impaired residents (Mollica, 2002). How is this affecting RCFE operating budgets and how should it affect MediCal reimbursement rates?  And again, how is this affecting quality of care?  And again, I don’t think we know.

Data Void

In the skilled nursing model, tracking and sharing data is required for Medicare certification and is widely available to inform public discussions.  In the assisted living care model, however, there is no certification or licensing mechanism that requires facilities to record or report data on resident care or otherwise (Kane R. A., 2007).  

As a result, research on RCFE quality of care and costs are supplied by two, third-party sources—academic researchers and industry groups.  This puts policy discussions at a disadvantage.  Due to small sample sizes, self-selection, geographic restrictions and other issues resulting data may not be strong enough to use as the basis for state-specific policy (Hernandez M. a., 2007).  

Yet, policymakers need a through understanding of the relationship between care and costs and how these improve or hurt resident outcomes to maximize programs like MediCal’s Assisted Living Waiver Program (Zimmerman, 2005).  As the private supply of assisted living beds now outpaces the growth of MediCal-funded beds, and California considers an expansion to MediCal’s Assisted Living Waiver Program (ALW) under AB 50, policymakers would be wise to put in place a consensus-driven plan to start capturing data on RCFEs in order to understand the real costs and real benefits going forward.