RN services to be "on-call" for more than a single facility. For larger facilities, a staff RN might be appropriate and feasible on a 24-hour basis (this staffing is already in existence for many nursing homes, either because it is required or on grounds of good practice), but for smaller facilities and in less wealthy Medicaid jurisdictions, the more economical sharing arrangement might suffice. This recognizes that some increments of quality might have to be traded off in the name of reasonable expenditure constraints and alternative claims on Medicaid and Medicare dollars.

Second, the 24-hour RN coverage mandate contained in recommendation 6-1 is subject to appropriate waiver. No criteria are specified in this waiver provision. Some committee members believed that the waiver should apply only when RN personnel are unavailable; others felt that waivers are appropriate when economic considerations make the requirement unwise in terms of cost–benefit analysis, especially in light of the opportunity costs associated with the 24-hour RN requirement in some foreseeable situations. Further, the "unavailability" standard inherently has an economic dimension, since the unavailability problem would be reduced or eliminated if money were no object and the price were, therefore, right.

Despite the flexibility implied by the term "coverage," I reluctantly state my disagreement with recommendation 6-1 because it is not based on careful consideration of evidence and a balancing of competing claims on public resources; rather, the Recommendation was reached without consideration of alternative uses of public funds or consequences from this proposed new mandate.

My substantive concerns have two components. First, the committee made this recommendation without any hard evidence about the costs involved or about the value of the benefit to be derived. Second, inadequate consideration was given to the desirability of allowing states freedom to set priorities and allocate public funds.

(a) There were few data presented or discussed regarding the cost of recommendation 6-1. There was an estimate provided by the nursing home industry that each additional hour of mandated nursing service would result in an increased nursing home cost for Medicare and Medicaid of $3.4 billion per year.

One cannot just multiply $3.4 billion per year by the additional 16 hours proposed in recommendation 6-1 to calculate the incremental cost of the proposal above existing expenditures. Many nursing facilities satisfy the proposed standard, but that number was not presented to the committee during its deliberations regarding recommendation 6-1. Further, the Recommendation does not necessarily call for additional hours of nursing service but only for upgrading the quality of nursing service. Thus, the industry's estimate does not provide an appropriate measure of the incremental cost of the committee's proposal. The problem is that the committee had no evidence to determine how many facilities would be affected and to what extent. Estimation of cost in such circumstances is

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