Two views: The quality question

At a glance…

Bob Gatty highlights two reports on the state of quality in long-term care.

Industry lobbyists, intent on blocking proposed Medicare cuts in health reform legislation, were armed with two new reports this fall-one from the industry, the other from the government-both of which they painted as supporting their argument that reductions in federal funding levels would jeopardize care for millions of residents.

On September 28, the American Health Care Association (AHCA) and the Alliance for Quality Nursing Home Care (Alliance) released what they called “the nursing, post-acute, short-term and rehabilitative sector’s first comprehensive report examining quality trends in the nation’s nursing homes.”

They said the report “highlights the positive evolution of skilled nursing and rehabilitation facilities along with the subsequent benefit to cost-effective seniors’ care; consumer and workforce satisfaction; and other key, quantifiable measures of quality, including public policy recommendations for moving quality forward.”

In a statement saying the healthcare finance reform plan proposed by Senate Finance Committee Chairman Max Baucus (D-Mont.) in mid-September was a “step in the right direction in terms of protecting hard-fought quality gains now benefiting patients,”*

Editor’s note: At press time, the Senate Finance Committee’s bill was being melded with another measure approved by the Senate Health, Education, Labor & Pensions Committee for consideration by the full Senate. Then, lawmakers must work out a compromise between the Senate-approved bill and still different legislation being developed in the House. One major House bill contains $32 billion in Medicare cuts for nursing homes over 10 years.

AHCA President and CEO Bruce Yarwood and Alliance President Alan Rosenbloom said their quality report provides an “unbiased, objective view of what has happened with quality in nursing homes since we began the
Quality First initiative in 2002.”

They said the report’s findings are “highly relevant to the ongoing healthcare reform debate,” and promised to emphasize it during discussions with lawmakers and their staffs.

The report essentially relies on findings from a number of researchers and research organizations, such as Avalere Health; Vincent Mor, PhD, professor and chair of the Department of Community Health at the Brown University School of Medicine; Steven Littlehale, senior researcher at PointRight; My InnerView results; and analyses of publicly available government data.

Some of the key findings identified by the two organizations:

• There is an apparent relationship between adequate reimbursement and quality improvements, access to quality care.

• Facilities have evolved to meet the special demands and needs of an aging population, with greater focus on post-acute care, with the length of stay of most patients now fewer than 90 days.

• Quality has improved in many areas, but work remains. Measurable improvements include a decline in use of physical restraint and the amount of pressure ulcers and improvements in such areas as weight loss, dehydration, and levels of patient activity and pain management.

• Existing metrics don’t reflect the different patient populations in nursing and rehabilitation facilities or the increasing specialization that has resulted.

• Patient satisfaction levels have increased, with 85% of consumers rating their overall satisfaction and recommendation for the facility to others as either “excellent” or “good”, up 3% from 2007 to 2008.

In the report, researchers made these additional observations:

• Both the proportion of homes achieving high levels of nursing staffing and those falling below minimum levels has increased.

• Most existing staffing measures ignore the fastest growing segment of facility staff-therapists who are concentrated in high-Medicare facilities.

• While the use of psychotropic drugs seems to have increased, most is attributable to ongoing increases in antidepressant use, while growth in antipsychotic use has leveled off.

• Incontinence among long-stay residents has worsened even though there is evidence that toileting programs can be effective.

• The results of state regulators’ inspections of nursing homes are not consistent with the measured outcomes.

It was those state inspections that were at the heart of the second report, published by the Government Accountability Office (GAO), which estimated that nearly 4% (580) of the roughly 16,000 nursing homes in the United States “could be considered the most poorly performing.” That compares to the 136 homes actually selected by states as Special Focus Facilities (SFF)-those identified as having the worst records of deficiencies that need to be corrected within individual states.

However, GAO pointed out that the SFF program was structured so that every state (except Alaska) has at least one SFF, even though the worst-performing homes in each state are not necessarily the worst in the nation. GAO came up with its new estimate by applying the SFF methodology, developed by the Center for Medicare & Medicaid Services (CMS) on a nationwide basis.

GAO found that the most poorly performing nursing homes in its analysis had notably more deficiencies with the potential for more than minimal harm or higher and more revisits than all other nursing homes. For example, the most poorly performing homes averaged about 56 such deficiencies and two revisits, compared to about 20 such deficiencies and less than one revisit for all other homes. GAO said the most poorly performing homes tended to be chain affiliated and for profit and have more beds and residents.

GAO recommended that the CMS administrator consider a home’s relative performance nationally when allocating SFFs across states and take actions to refine the SFF methodology to improve the identification of SFFs. GAO said CMS generally agreed in principle with its recommendations and said it would evaluate the effects of adopting them.

On September 29 in an AHCA news release, Yarwood responded that “Quality improvement is a dynamic, ongoing process, and there comes a time when some facilities who can not continue to provide the care that America’s seniors deserve must improve or even shut down.” He said the key to helping facilities improve is a “transparent survey process that recognizes quality and provides the resources for facility improvement.”

Yarwood pointed to a comment made by Dr. Mor and PointRight in the industry’s quality report: “It is clear that nursing home quality is multidimensional; what is becoming clear is that it is no more appropriate to compare all nursing homes with one another than it would be appropriate to compare an Obstetrics hospital with an Oncology hospital.”

Added Yarwood, “Our profession has helped lead the nation’s healthcare sector in terms of quality improvement, and the complexity of care delivered every day in skilled nursing facilities make it improper to attempt to compare-or rank-facilities to one another. Working together with all stakeholders is key to avoiding these misrepresentatives and to ultimately improving the quality of life for the millions of patients and families who rely upon us every day.”

Robert Gatty

Robert Gatty has more than 40 years of experience in journalism, politics and business communications and is the founder and president of G-Net Strategic Communications based in Myrtle Beach, South Carolina. He can be reached at bob@gattyedits.com.