Enough is Enough!

“What is being launched tomorrow is poorly planned, prematurely implemented and ham-handedly rolled out.” So said a press release “rocket” from the American Association of Homes and Services for the Aging (AAHSA), quoting President and CEO Larry Minnix on the eve of the federal government’s December 18 release of its Five-Star Rating System for nursing homes. Especially notable about this was the tone of the remarks—Minnix has been a leader over the years in fostering a collaborative approach between long-term care leadership and government in developing LTC policy. If ever there was a voice of “sweet reason” in this field, Larry Minnix’s was it. His comments on Five-Star, though, pulled no punches: “The Five-Star system is reflective of the way CMS has increasingly done business recently. Its ethos of working with providers has changed, in my experience, from collaborative and transparent to a heavy-handed compulsion to cram good, yet poorly executed ideas down our throats in the waning days of this administration…. Enough is enough!” Recently Long-Term Living Editor-in-Chief Richard L. Peck asked Minnix to elaborate.

Peck: I don’t recall ever seeing you so worked up before. Was it the Five-Star system, the way CMS handled it, or both?

Minnix: It’s both. When CMS met with us in early summer of 08, they asked us what we thought of this, and we said it could be a great idea, depending on how it’s implemented. They said they wanted to get it done by the end of the year and we said this sounded ambitious, what were they basing it on? They said survey and certification data, some Quality Measures, some stuff on staffing. Of course the issue is that the survey and certification process was and is deeply flawed and inconsistent from state to state, and even CMS admits to the inconsistency—the new rating system is being implemented state-by-state because CMS recognizes the inconsistency. As it turned out, CMS communicated but they didn’t collaborate. The next thing we heard was that CMS had had an open door meeting on this with only 500 sign-ups and they were disappointed. Then they invited us to review a PowerPoint on the new system—five days before its release! To make matter worse, no association or nursing home in America had access to the data—CMS said it was “unavailable,” but then they did release it to the Gannett News agency. One of our executives obtained it from the Des Moines Register and we distributed it to all the associations. And what is the situation now? Predictably, a number of problems have arisen with the system because they didn’t collaborate. The system could have been a lot more credible by now if they had.

Peck: Problems such as…?

Minnix: One big problem that’s emerging, and there are data supporting this, is that nursing homes that take in sicker people look worse in the system. I’ve gotten word over the past couple days that sub-acute patients are backing up in the hospital system because nursing homes are reluctant to take them anymore. CMS says they’ve consulted with experts on this, and they’re some credible people, but nobody knows what they’ve said. The bottom line is that somebody in government compulsively wanted to get this done before they left office and we don’t know why. Meanwhile, good reputations have been needlessly soiled, and our fear is that this could undo the progress we’ve made in quality improvement over the past several years.

Peck: What are some of your short-term recommendations for facilities having to deal with this?

Minnix: First, check out the data to make sure they’re accurate. They’re not for a lot of places. CMS does have people working on this now, but this problem could have been avoided if they had worked collaboratively. Second, if you do need to improve, do so even more quickly, because the basic idea of Five-Star is a good one; good, sound data will help people. Third, concentrate on your staffing issues. CMS isn’t asking nearly enough questions about this; they’re focusing on nursing hours provided but, unfortunately, they’ve based this on payroll snapshot data that, in some cases, were gathered on holiday weekends—not exactly representative staffing. We think there should be focus on staff retention and agency utilization as well as hours and, if these had been added upfront, the public would be getting a lot better information.

Peck: This past year AAHSA released its report on the survey and certifications system called “Broken Beyond Repair.” Have you seen any improvements as a result?

Minnix: Very little. We had 31 recommendations for improvement and, right now, it’s a dead elephant in the room. The system needs to be completely overhauled but they’re tinkering around the edges. It measures the wrong things, is inconsistent and unjust, and is underfunded. They do not have enough trained, qualified people or technology systems to keep up.

Peck: When you alluded before to Five-Star’s possibility to interfere with quality improvements underway, you referred in part to Advancing Excellence which, to my mind, closely resembles the QIO approach taken by CMS some years ago. With this turnaround, do you think facilities will still be willing to participate in this sort of thing?

Minnix: We hope so. We had encouraged CMS to relate Five-Star to Advancing Excellence activities because it’s the only area where we have credible data as to whether nursing homes are really improving or not. Five-Star doesn’t even refer to this data and has no correlation with what’s been going on with Advancing Excellence. Here you have the three national associations rallying the troops to participate in Advancing Excellence and not only does CMS prematurely roll out a flawed system, it totally ignores Advancing Excellence—our best hope for quality improvement.

Peck: Which is odd, since CMS is put forward as a lead agency for Advancing Excellence. It seems as though they’re ignoring themselves.

Minnix: Richard, it makes no sense. It’s certainly a departure from the way CMS worked with consumers, providers, labor, the broad base of stakeholders, in years past. When (Tommy) Thompson (then HHS secretary) and (Thomas) Scully (then CMS Administrator) rolled out their Quality Initiative, we provider associations literally sat in a room with them and we were all for the idea. We had the venues where the details were hammered out, knock-down and drag-out, ad nauseum. But when we were done, everyone could stand together before the public and say, we’re doing this together. It’s not perfect, but it’s a start. We did the same thing with Medicare Part D, and then with Advancing Excellence. And now this. I don’t think the leadership of this program understands the difference between communication and collaboration.

Peck: I’ve always had the impression that, when Tommy Thompson left (in 2005), the collaboration died. Am I correct?

Minnix: (chuckles) Let’s just say, you’ve noticed a difference and so have we. Thompson, Scully and (former CMS Administrator Mark) McClellan were all collaborative people, but something was lost along the way. I’m not saying that today’s leadership are bad people, but they have a different management style that is not serving the public well.

Peck: Are there signs for hope in the new Administration?

Richard Peck

Richard L. Peck was editor in chief of I Advance Senior Care / Long-Term Living for 18 years. For eight years previous to that, he served as editor of the clinical magazine Geriatrics. He has written extensively on developments in the field of senior care and housing.