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Points to Consider in the CR Analysis

2006; Elsevier BV; Volume: 7; Issue: 9 Linguagem: Inglês

10.1016/s1526-4114(06)60231-x

2377-066X

Susan M. Pettey,

Technology and Data Analysis

MS. PETTEY has directed health policy and advocacy programs for long-term care physicians, administrators, and other professionals, including AMDA and the American Association for Homes and Services for the Aging. Her experience also includes work with the Health Care Financing Administration (now the Centers for Medicare and Medicaid Services) and the National Association for Home Care. She currently is a health policy consultant. The recent Consumer Reports analysis on nursing home quality paints a bleak picture of the impact of nursing home reform efforts. According to Trudy Lieberman, director of the Center for Consumer Health Choices at Consumers Union, the quality of care provided in too many nursing homes simply has not lived up to the promise of the nursing home reform provisions of OBRA '87. Reports of poor care always are disappointing to the physicians and health care professionals who work so hard in the field. While some may take issue with aspects of the report, it does call attention to two critical elements that are essential to improving quality: nurse staffing and enforcement. The Consumer Reports (CR) analysis highlights the critical role that nurse staffing plays in the quality of nursing facility care. But we have known that for a while. Reports by the Institute of Medicine in 1996 and 2001 recommended a higher nursing facility minimum of 24-hour registered nursing care. The 2002 Centers for Medicare and Medicaid Services (CMS) report on “Appropriateness of Minimum Nurse Staffing Ratios in Nursing Facilities” was designed to identify staffing thresholds below which quality of care was compromised and above which there was no further benefit of additional staffing with respect to quality. CMS found the threshold to be 4.1 hours of total nurse staffing time per patient. CMS backed away from making recommendations for ratios or recommended staffing levels, however. Instead, the agency recommended additional studies of other factors, such as better management practices, reduced turnover, and improved training that could mitigate the need for increased staffing. CMS suggested minimum nursing expenditures as an alternative to staffing ratios—a concept that appears to have garnered little interest. Of course, the cost of increased staffing would be significant. CMS found that the staffing threshold identified would require large staffing increases of 13%–21% for nurse aides and 5%–9% for nurses. In 2001 dollars, such improved staffing would have cost in excess of $7.6 billion, or an increase of 8.4% over current nursing facility expenditures. The current national staffing hours listed on CMS's Nursing Home Compare Web site are 1.2 hours for licensed nursing staff and 2.3 hours for nursing assistants, for a total of 3.5 hours per resident. The National Citizen's Coalition for Nursing Home Reform continues to push for mandated nurse staffing ratios of 4.1 hours of combined staff care. There are legitimate arguments to be made against mandated staffing ratios: First, ratios do not take case mix into account; second, such mandated ratios do not reflect alternative staffing models, such as universal workers; and third, simply having more staff does not necessarily guarantee a higher quality of care. Yet, the case for increased nurse staffing seems clear, so the question is how to get there. In lieu of increased regulations, the administration prefers market-based approaches with a focus on transparency, such as the requirement for posting nurse staffing levels in each nursing facility. A modest proposal may be to include on the posted staffing notice the 4.1-hour CMS threshold staffing level below which quality of care was compromised. Would that create market pressure for nursing facilities to increase staffing levels? Would consumers and government payers be willing to pay for increased staffing? One of the most troubling aspects of the CR report is its assertion that poor-quality facilities continue to operate with little effective enforcement. After all, it was the continued poor performance of a consistent group of nursing facilities and their “yo-yo” compliance records that prompted key nursing home reform provisions of OBRA '87. Stronger enforcement tools with eight discretionary remedies, including civil monetary damages and bans on admissions, were to be part of the solution for dealing with these repeat offenders. The CR report presents a case that some of those enforcement remedies simply are not being applied to situations for which they are appropriate. CR noted that, while the number of deficiency citations written by state surveyors has increased since 2003, surveyors are writing fewer citations that denote actual harm. The Department of Health and Human Services' Office of Inspector General (OIG) has been critical of state and federal enforcement efforts for some time. When facilities are out of compliance for certain time periods or have deficiencies that constitute immediate jeopardy, states are required to refer the cases to CMS for enforcement action, including mandatory sanctions. Earlier this year, the OIG found that CMS failed to apply mandatory sanctions and terminate Medicare contracts for nursing facilities not in compliance with quality standards in 55% of cases requiring this remedy during 2000–2002. Subsequent reviews by the OIG revealed that all of the facilities not terminated had, in subsequent surveys, new cases of noncompliance serious enough to again require referral to CMS. The OIG also found that in cases requiring denial of payment for new admissions, 28% were never applied and 14% were applied late, largely because of late referral by state survey agencies. The OIG also reported in 2005 that fines tended toward the lower end of the allowed range, with the median (daily) fine for immediate jeopardy cases of about $4,000, while the median fine for less severe cases was $250. Out of $81.7 million in fines that CMS imposed between 2001 and 2002, only $34.6 million had been paid by the end of the year. Those figures do not consider changes in penalties that may have occurred as a result of the appeals process. Additional recent OIG reports have faulted states for failing to report about 8% of mandatory referrals to CMS, and for failing to investigate serious complaints within required time frames. The CR analysis asserted that nursing facilities wield considerable political clout in states, and are able to weaken regulatory efforts, although it cited only one example (in Arkansas). “The report does correctly point out the intense political pressures that are exerted in many states to let poor performers off the hook and minimize consequences,” according to Dr. Steve Levenson, president of AMDA. Prior to release of the CR report, CMS had announced efforts to expand its Nursing Facility Quality Initiative (see related article on nursing facility payment increases, on page 13). In addition, health care providers, caregivers, consumers, and government agencies are planning a 2-year campaign, Advancing Excellence in America's Nursing Homes, that will monitor key indicators of nursing home quality, including the critical role of nursing home staff in providing that care. AMDA members and staff will be active in the program. The campaign will seek to: ▸ Reduce occurrence of high-risk pressure ulcers. ▸ Reduce the use of daily physical restraints. ▸ Improve pain management for longer-term nursing home residents. ▸ Improve pain management for short-stay, postacute residents. ▸ Establish individual targets for improving quality. ▸ Assess resident and family satisfaction with the quality of care. ▸ Assess staff retention. ▸ Improve consistent assignment of nursing home staff, so that residents regularly receive care from the same caregivers. At the press conference announcing the CR study, Ms. Lieberman was asked about the characteristics of a good nursing home. She looked beyond the raw numbers included in the report, and discussed the elusive qualities that she saw as related to individualized care and quality of life. Her favorite example was a nursing facility that threw a 21st birthday party for a young quadriplegic resident, complete with a drop of beer on the lips of the young man who was coming of age. Ms. Lieberman identified another strong factor that she said influenced care: “an intangible leadership of commitment to care” that enables facilities to tackle the difficult problems of improving care. “You know it when you see it,” she added. That need for dedicated, strong leadership is where AMDA members come in. Studies have shown that an involved medical director has a positive impact on facilitywide outcomes. Medical directors can be the driving force behind significant improvements in quality of care in nursing homes. Those improvements, coupled with appropriate, swift, and sure enforcement actions against poor performers, would do much to bring about a culture change so that quality care is the norm in America's nursing homes.