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Focus on Excellence program delivers money to some care centers, federal deficiencies to others



Everyone agrees the program is worth the money. But not everyone is happy with what is being done with the money. Some state legislators are disgruntled enough they have called for a suspension of the program.


Last year, the Oklahoma Health Care Authority began doling out incentive payments to elderly care facilities through the Focus on Excellence, or FOE, initiative. It was approved by the Legislature under the Oklahoma Medicaid Reform Act of 2006. The idea was to reward Medicaid participating facilities for quality care with bonus checks based on a star-rating system. Nearly $19 million has been handed out.

But an analysis by Oklahoma Gazette finds about a third of the nearly 300 facilities across the state that are enrolled in the program exceeded both the state and national averages for health deficiencies during the past year. Some facilities tripled the average deficiencies mark for Oklahoma, yet were ranked above average by the state's star-rating system and received more than $100,000 each in incentive payments.

Grace Living Center, 2400 S.W. 55th in Oklahoma City, earned a five-star rating and has received more than $179,000 in incentive payments. Yet the nursing home recorded 19 deficiencies by the federal government between May of 2008 and July of this year. The state's average is 12 deficiencies per nursing home while the national average is eight.

Green Country Care Center in Tulsa also has a five-star rating, although it was marked with 41 deficiencies. The facility was still paid more than $119,000 in incentive money.

But the head of OHCA, which operates the Medicaid and FOE programs in Oklahoma, defends the system.

"To our knowledge, and in the opinions of national experts in the field, Oklahoma's program is the most comprehensive and among the best in the nation," said Mike Fogarty, CEO of the OHCA.

Fogarty is referring to experts cited in a report on the state's FOE program by the Pacific Health Policy Group. The report did conclude Oklahoma's program is the most comprehensive, but it should be noted only seven states have a similar program.

The report did not give the program a total clean bill of health, but was favorable toward most of FOE's initiatives and suggested some minor changes. That is not what a bipartisan group of legislators has in mind when calling for a suspension of the program.

"We're are not going to accept minimal tweaks and whitewash what we are trying to do here," said Rep. Richard Morrissette, D-Oklahoma City, who has led an effort to examine the state's nursing home care for more than a year.

Legislative complaints about the program include the star system grading scale, which critics believe is too lenient and uses some flawed data, and that the program has not been implemented correctly.

But on the same day legislators were calling for a suspension, the director of the independent study took issue with some of the complaints in a statement.

"It should be noted that we did not find the program to be systematically rewarding low quality facilities," said Andrew Cohen, director of Pacific Health Policy Group. "In fact, Focus on Excellence awards incentive payments across a broad spectrum of measures, such as resident quality of life and resident-family satisfaction, which are not directly addressed through the traditional licensure and certification process."

But Oklahoma City's South Park Health Care Center earned just one star and had 34 deficiencies, yet received more than $152,000 in FOE payments. In fact, more than one-third of the facilities in the program received two stars or less, which would be considered below average ratings, accumulating millions of dollars in bonuses.

The state hands out quarterly bonuses, which are based on survey data submitted by the facilities every month. The survey has different categories from which a facility is scored. Each category can earn the facility FOE funds.

OHCA spokeswoman Jo Kilgore said the performance measure payments only comprise about 2 percent of a facility's overall state allocation. This year, more than $12 million was earmarked for the program from OHCA.

The independent report cited timing and different measuring scales as some of the reasons why some state facilities rate high on the FOE star system, yet have several federal deficiencies. The star rating listed for a facility, which can be found at, are the most recent quarterly rating. The federal deficiencies, found at, are an accumulation of the past year. A facility listed to have 20 deficiencies may have acquired those marks in previous quarters, but if there were no deficiencies for the most recent quarter, the facility automatically gets five stars.

This was a flaw not only pointed out by the legislators, but the independent report as well.

"The methodology used by Focus on Excellence generates higher average ratings," the report said. "Focus on Excellence shows 80 five-star facilities, versus only 18 for Nursing Home Compare," referring to a Web site run by the Centers for Medicare and Medicaid Services.

The legislators also voiced concern about the method by which data is supplied for the program. Surveys are filled out by the staff and residents of the nursing facilities, which lawmakers worry could be abused since there are few ways to check for accuracy.

Rep. Scott Inman, D-Del City, said there is undue pressure to fill out favorable surveys.

"We've got to allow for an independent third party to come in and accurately gather that information so the five-star rating system can be effectively used," Inman said.

The independent report said it found no evidence of tampering with the survey, but that the perception exists from the public and nursing home providers that the process could be "gamed." It recommended better transparency on the state's Web site to provide more information and data from the surveys, as well as previous quarter star ratings.

The legislative group calling for changes said if the program is not changed, they could ask the governor to issue an executive order or introduce legislation to mandate changes next year. "Scott Cooper


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