Paul Willging Says…


It all comes down to education

Having spent so much of my professional career in the public-policy arena, and now working in an academic environment, I’m often asked what the essential differences are between the two. (Actually, to be totally honest, I’ve never been asked that question-but it seemed like such a natural introduction to this column I thought I’d ask it myself.)

Truth be told, our perception of issues is, to a considerable extent, a function of our occupations. Representing long-term care as a lobbyist for nearly two decades certainly offered me a different perspective on issues facing the industry from that of my current avocation: preparing young men and women for careers in long-term care management, research, and public policy. That doesn’t mean the issues themselves are different. From inside or outside the university, the dilemmas facing long-term care administrators are the same: declining census, marketplace competition, and extreme government scrutiny of quality and finance. These issues are on the radar screen no matter where we work in long-term care. But how one accommodates to them, how one prepares to confront them, how one adapts to them-that’s how our perspectives might differ.

Certainly, education is the key, in both settings, to dealing with all the issues facing long-term care providers. The distinction lies in the audience. As an industry spokesperson in Washington, the focus of my educational efforts was on policy makers, both in Congress and the executive branch. As a professor, my focus is on students. Yet, although the purposes underlying the educational process in the two settings might differ, the essential function remains the same.

In lobbying, the purpose of education is to proselytize. To “proselytize” means to try to convert someone to a religious faith or political doctrine. We weren’t much into religion (at least professionally), but we certainly were paid to talk politics. In the academic environment, the purpose of education is to enhance understanding for a different purpose; namely, improving functional capacity. Whether we academics are educating future policy analysts, researchers, or managers, our goal is to provide students the understanding and tools whereby they can perform those functions to the best of their innate abilities.

In dealing with the issues of census and marketplace competition, I devoted much of my energy as a lobbyist in Washington to the regulatory environment. We in the industry wanted to have an even playing field, with similar rules applicable to all providers along the long-term care continuum. In the reimbursement and financial arenas, the inadequacy of federal and state payments consumed most of our attention. With respect to quality, we wanted to show state and federal government the capricious and arbitrary nature of surveyors’ quality measurement techniques.

Were we wrong to do this? Of course not. That was our profession, and there is nothing unethical or immoral about it. But were we successful? The answer to that question is more equivocal because, to some extent, the forces we were fighting were much more a product of larger social and fiscal questions that did not lend themselves to easy resolution, no matter our technical skills as lobbyists. Indeed, to successfully lobby, we had to at least understand those broader systemic concerns.

Problems with census and the marketplace are not a simple response to the government’s inadequate regulatory oversight. Rather, they’re the result of an increasing population of affluent seniors and their families who can now purchase products, including long-term care, more in tune with their individual preferences. Nor do state governments underpay providers (and they certainly do underpay) out of a sense of malevolence. No, it’s because of the incredible burden that our current system of long-term care financing places on limited public funding sources. Moreover, increasing regulatory scrutiny could well be a result of legitimate public frustration over the (thankfully) small number of providers whose concern about quality is suspect.

What does all this say about the respective roles of lobbyists and educators? Well, for the lobbyist, it might suggest making an attempt to deal with larger social issues while simultaneously looking for immediate relief. And I commend today’s trade associations for beginning, belatedly perhaps, to pay as much attention to the underlying issues of quality and long-term financing reform as they do to the regulatory burden and short-term reimbursement relief. In fact, neither perspective can be ignored, and neither can nor should be pursued to the detriment of the other. Both, within their own time frames, will make for a more secure industry, if dealt with successfully.

For the educator, however, I think it’s equally important that we teach our students, even those oriented primarily toward a career in management, to distinguish between technical and systemic accommodation to the issues facing them as administrators, so that they might better understand their interplay and how they affect one another.

Take the nursing home Prospective Payment System (PPS) as an example. PPS is a payment methodology, no question about that, and the successful administrator needs to understand the mechanics of categorizing Medicare patients in one of multiple Resource Utilization Groups (up to 53 at last count). But those are techniques that will do little for the administrator who, at the same time, doesn’t pay attention to the underlying systemic changes brought about by PPS. Basically, PPS has changed the very essence of long-term care reimbursement.

It has developed a market-based pricing system, recategorized patients based on their acuity rather than location, and restructured the functional requirements for long-term care administration. The successful administrator will need to be intimately familiar with his facility’s cost structure to ensure compatibility with market-based prices now paid by Medicare. He will have to be conversant with the clinical issues that used to be the exclusive domain of the director of nursing. The administrator will further need to understand and practice the art of successful negotiation with the myriad vendors lining up outside his door to provide PPS-related services.

An example, if I may: I think the hubris exhibited by many of the multifacility corporations prior to the implementation of Medicare PPS resulted, in part, from their own failure to understand the systemic changes brought about by prospective payment. Before PPS, the most successful corporations had been well rewarded by diversifying into multiple specialty services that were paid for on a cost basis. Getting paid your costs, plus overhead, turned out to be very lucrative, indeed. And many a multifacility corporation benefited from such anomalies of Medicare reimbursement. They went on to lose their corporate shirts in failing to recognize in a timely enough manner that corporate ownership of such ancillary services (e.g., therapy companies) became a drag on profitability when PPS turned such “revenue centers” into fixed payment “cost centers.”

Not to understand the long-term implications of any short-term decisions will create problems for even the most technically proficient administrator. But let’s not limit our discussion to Medicare. Example number two: Many Medicaid systems used to incorporate staffing add-ons within the context of cost-based reimbursement methodologies-the theory being, of course, that, with such an add-on, administrators would increase facility staffing. Unfortunately, all of us can cite far too many examples in which the onetime add-on was used, not to add staff, but to enhance that year’s bottom line. That’s all well and good (fiscally, anyway) as long as your state’s reimbursement system didn’t base the next year’s rates on the prior year’s costs. Now your shortsighted approach to maximizing Medicaid reimbursement has adversely affected not only your future rates, but those of other providers in the state, as well.

What about quality? The current system might well be an incredibly wasteful application of time and resources, but not to devote sufficient attention to it-not to understand it-will work to even the most dedicated administrator’s disadvantage. You’ve got to know the system if you want to survive. But if you really do want to provide quality care, familiarity with the arcane provisions of survey, certification, and enforcement is not enough. The current system doesn’t measure quality, and it certainly doesn’t improve it. The successful administrator is going to have to rely on his own professionalism to enhance care in his facility. He is going to have to master the principles of quality management, from assessing outcomes and patient satisfaction to empowering staff to improve them.

Perhaps the best example of distinguishing between technique and systemic change is in the area of market share. In my course on long-term care management at Johns Hopkins University, I’ve added marketing as a critical part of the syllabus. Of course, successful marketing depends as much on the product as it does on the techniques used to market it. It’s fascinating to talk to students about this. Its fun to engage them in discussions about how one best identifies qualified prospects, how to create a lead base, and what a creative follow-up program might look like. None of this, though, gets to the underlying issues, which might just be the most critical factors in determining the success or failure of your sales and marketing program.

Nursing facilities, for example, have lost market share not so much because of an inability to market (i.e., lack of technique), but because the buying public, the government included, has grown tired of their product. That’s not the facility’s fault; it was providing the product that the primary payer-the government-demanded. But the new customer is the private payer. Private pay has propelled the growth of assisted living. For nursing facilities to survive, their product has to be competitive with this, and that means paying even greater attention to customer satisfaction, generating referrals, and relating to the community at large.

One last point: The sacrosanct rule critical to success in either field of endeavor, be it lobbying or academic education, is that your information should be accurate. I don’t care whether you’re educating senators or doctoral candidates. Do not misinform. Do not “wing it.” When discovered massaging the numbers, nothing can do you in more quickly.

Admittedly, we may overdo this in the academic setting. I remember so vividly being admonished by one of my colleagues here at Johns Hopkins when I failed to put citations in my PowerPoint presentations. (I still don’t; nothing can diminish the impact of a slide show more than line after line of footnotes.) But I certainly do make sure that I have a citation close at hand for each factual statement I present in class.

That respect for accuracy is equally valid in the public-policy arena. A good example came up recently here in Maryland. The major teachers’ association in the state has been trying for years to improve the pension system for its members. As public employees, that means getting legislative approval and funding. This year they thought they had a pretty good shot at it since Maryland, along with many states, is somewhat flusher than in years past. Unfortunately, the teachers based their campaign on the obviously dramatic statement that Maryland teachers’ pension benefits were the lowest in the nation.

When making such statements, you had best be sure you’re not comparing apples and oranges-which, as it happened, Maryland’s teachers were. All it takes is one mistake like that to put your lobbying campaign in the deep freeze. “They keep saying, ‘We’re last in the nation,’ and that’s not true, and that bothers me a little bit,” said one legislator (unfortunately for the teachers, the point person on pensions in Maryland’s House of Delegates). “We’re actually in the middle.” Legislators are always looking for excuses not to fund things, and that ill-advised attempt to gild the lily essentially did the teachers in (and my disappointment is all the more extreme in that my eldest daughter is a Maryland public school teacher).

In the end, our roles are similar, both lobbyists and educators. Our representatives in Washington and state capitals need to continue with the thankless and endless job of educating public policy makers (preferably with accurate data). But our lobbyists need to understand the societal constraints with which our elected representatives need to contend. Educators, for their part, have no choice but to focus on the ever-increasing complexities of the management, payment, and regulatory systems that confront administrators. But they, too, need to understand the incredible systemic changes overtaking our field.

The industry is not what it was yesterday. And rest assured, it will look different tomorrow from what it does today. The only constant is change, and the change we are confronting in long-term care is as dramatic as anything we have ever faced in the past. Education can help us adapt to change, but it too must accommodate. It must recognize that change can be societal, systemic and technical. Education must adapt to all of that, and ignore none of it.

In so doing, education might well be the salvation of us all, whether its “students” are public- or private-sector’based.

To send your comments to Dr. Willging and the editors, e-mail
Paul R. Willging, PhD, was involved in long-term care policy development at the highest levels for more than 20 years. For 16 years as president/CEO of the American Health Care Association, Dr. Willging went on to cofound the successful Johns Hopkins Seniors Housing and Care postgraduate program (cosponsored by the National Investment Center for the Seniors Housing & Care Industries), and later served as president/CEO of the Assisted Living Federation of America. He has enjoyed an equally long-lived reputation for offering outspoken, often provocative views on long-term care.

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