It's time to stop long-term care state rankings
Minnesota routinely is named best state for long-term care, as it was last week in AARP's 2014 scorecard. AARP held a panel discussion to unveil the rankings, and of course an official from Minnesota was on hand to share his state's secret sauce. But the panel also featured a speaker from Mississippi, one of the lowest-ranking states. I came away thinking that Minnesota actually might not have much to teach Mississippi — and questioning what these types of state rankings accomplish.
Minnesota has built its renowned system of long-term services and supports largely by devising a strategic plan that has buy-in from providers, advocates and other stakeholders, said Loren Colman, assistant commissioner of continuing care for the state's Department of Human Services. He also said it's important to build strong partnerships with nursing homes rather than seeing them as “the enemy” preventing home- and community-based care. And he recommended that states take risks and not be afraid of unsuccessful initiatives, as these will enable course corrections that lead to progress.
The importance of a strategic plan was hardly news to Mississippi panelist Kristi R. Plotner, director of the Office of Policy, Planning and Development at the Division of Medicaid, Office of the Governor. Mississippi put a comprehensive plan together in 2001, Plotner said at the start of her remarks. She also said that her office and others built partnerships with nursing homes, with assurances that expanding HCBS was not meant to put skilled facilities out of business. And she said, “It's important to take risks and step out there and do things that haven't been done before.”
In other words, Colman and Plotner have essentially the same approach to improving long-term care in their respective states. So why is Minnesota at the top of the heap and Mississippi near the bottom of the AARP scorecard?
There are some clues. Hewing to a well-publicized strategic plan for long-term care enabled steady progress even as different political parties came into power in Minnesota, Colman said. Mississippi's plan never got funded, and expansion of home- and community-based care has occurred largely as a byproduct of a freeze on nursing home reimbursements in the Magnolia State, Plotner said.
A few other interesting tidbits from the AARP report: Minnesota scored a 5.24 for “legal and system supports for family caregivers” while Mississippi scored a 3 (below the national average of 3.45). And out of 16 health maintenance tasks, Minnesota allows all 16 to be delegated to long-term services and supports workers. Mississippi allows three to be delegated.
It seems obvious that Minnesota lawmakers are much more committed to supporting long-term care improvement than those in Mississippi. Perhaps this is why LeadingAge CEO and President Larry Minnix opened the question-and-answer session by asking how the panelists have tried to get legislative support.
The panelists did have some interesting answers to Minnix's question, and it's certainly possible that advocates from Minnesota or Oregon might be able to share lobbying strategies with lower-ranking states. Yet it also seems clear that some state governments are more open to boldly reforming long-term care than others, due a mixture of historical forces, economic health, resident demographics and other factors.
All this leads me to think that it's a bad idea to present reports like this one as “state scorecards” or “state rankings.” Doing so does generate buzz — everyone likes to see how his or her state compares. But these lists suggest there's a kind of competition going on, and that Mississippi could catch up to the leader states simply by learning from them. In fact, the top and bottom states might already be pursuing similar strategies, and some states will succeed to a far greater extent than others because of factors that are all but set in stone.
The authors of the AARP report basically acknowledge as much. While “state leadership and vision make a difference,” the “first” takeaway from their report is that “we need a rational approach at the federal level to guide the states and to establish standards for LTSS system performance below which no state should fall.” My interpretation: The deck is stacked against reform in certain places, so we need Congress to actually do something more than, say, convening a commission to draw up a hasty report.
This message got lost somewhere. It's not until the last sentence of the official AARP press release that the word “federal” appears, in a quote from SCAN Foundation President and CEO Bruce Chernof, M.D. (chairman of a certain Congressional commission that drew up a hasty report). Writing about the scorecard for Forbes, the great long-term care journalist Howard Gleckman never used the word “federal,” and he said that the report showed how states could make improvements if they just “look a little harder” or “committed the resources.”
I think the AARP scorecard is a great document, full of interesting and revealing statistics. A ton of work obviously went into it. But if the authors really believe that federal intervention is so urgently needed, I recommend they frame their findings differently next time. How about a title like, “Long-term services and supports: Minnesota shines, Congress stinks.”
I think that report still would grab people's attention, and it might shift the conversation into more productive territory.
Tim Mullaney is McKnight's Senior Staff Writer. Follow him @TimMullaneyLTC.