On a recent What the Health podcast, where I’m a frequent guest, we took some listeners’ questions. One was about what CMS does with all the data it collects on quality from health care facilities and providers – and whether there’s any evidence that the quality reporting actually improves outcomes for patients. Continue reading
CaliforniaWatch’s Christina Jewett and Agustin Armendariz put some serious time into an investigation of the results of a 2004 law that directed an extra $880 million to California nursing homes, yet didn’t come with a whole lot of safeguards as to how that money would be used. It was intended to help the homes ameliorate staffing shortages and boost wages, but, they write, at least “232 homes did just the opposite. They either cut staff, paid lower wages or let caregiver levels slip below a state-mandated minimum.”
Many nursing homes appeared to use the cash infusion to help bolster their bottom lines, according to a California Watch analysis of state nursing home data. Among the 131 homes that cut staff by 2008, the median profit was 35 percent more than other homes in the analysis.
At the same time, the analysis shows, about two dozen homes that made the deepest caregiver cuts had about one-third more deficiencies than other state facilities. State inspectors noted a litany of violations that included neglecting bedsores and giving patients the wrong drugs.
And, furthermore, there appears to be a loophole in the law that allows that extra money, which again was intended to improve care, to be spent fighting all these inspection violations.
When homes are cited with serious violations, the 2004 state law helps bail them out.
Homes are allowed to bill for administrative costs such as legal fees. That means facilities can charge the state to fight state-issued fines and citations for substandard care.
How they did it
Jewett’s story is accompanied by a detailed breakdown of how she arrived at her conclusions. It focuses on what she and CAR specialist Armandariz did with the data and only touches on how she acquired it. She also discusses how she shared her data and conclusions with an industry group before publication and modified them slightly based on the group’s input.
Supplementary materials from CaliforniaWatch
- Graphic: Track how nursing homes are paid for Medi-Cal patients
- Graphic: How one nursing home chain boosted profits while staffing rates fell
- Graphics and database: State boosts nursing home pay by $880 million
The San Francisco Business Times‘ Chris Rauber writes that the Center for Investigative Reporting, the California news nonprofit that produces CaliforniaWatch.org, has continued its fundraising run with $440,000 from The California Endowment. The money will be used to launch a community health reporting beat and to hire a “public engagement liaison,” Rauber writes.
CIR has raised more than $6 million over the last 18 months, including a total of $850,000 in March for its California Watch and other initiatives, officials said April 14.
Over the last year, CIR’s staff has nearly tripled, from 8 to 22, and four more hires are planned over the next two months, officials said. It launched California Watch, billed as the largest investigative journalism unit in the state, last September.
San Antonio Express-News reporters Karisa King, John Tedesco and Melissa Fletcher Stoeltje took advantage of a number of tools to assemble a broad investigation into the city’s nursing homes.
Slow action on nursing home problems
In the package’s centerpiece, the reporters plowed through 2,200 claims filed against the town’s 55 licensed nursing homes from 2006 to 2009 and found that investigators arrived long after the incidents in question and marked so many claims “unsubstantiated” that the state attorney general posted a notice advising residents that they should take even unsubstantiated claims into account when evaluating nursing homes. They also consulted ratings and visited 10 local nursing homes.
Photo by Susan NYC via Flickr.
With the ratings as a guide, the newspaper examined more than 3,000 pages of abuse and neglect investigations and annual inspections of 10 nursing homes with the lowest scores. It also reviewed dozens of wrongful-death lawsuits filed against local nursing homes to examine how Texas watches over its elderly.
In addition to a few dangerous homes and some disquieting anecdotes, the reporters found an unenforced reporting law:
(Department of Aging and Disability Services) also is failing to enforce a state law that requires nursing homes to report details about every resident who dies. State officials are supposed to analyze the fatality reports to publicize problems and trends, but that research isn’t being done.
To top off this tale of dysfunction, they also unearthed at least five cases in which would-be nursing home whistle blowers were fired.
Stoeltje added a sidebar on nursing home rating systems, their utility and their shortcomings. She addresses both the local Texas system and the federal Nursing Home Compare database. She talks to both nursing home operators and patient advocates; the operators tend to dwell on ratings’ weaknesses while advocates spoke on their strengths.
LIST: Examples of problems found at nursing homes
Six more examples culled from complaints and often backed with interviews.
MAP: Quality of nursing homesA Yahoo! map linking nursing home location, size and rating.
Texas Public Radio
Terry Gildea, host of a news discussion program called “The Source,” interviewed all three Express-News reporters about their investigation.
USA Today‘s Jack Gillum crunched the numbers and found that one-fifth of U.S. nursing homes have received two consecutive poor (one- or two-star) ratings in the federal Nursing Home Compare database since its launch in 2008.
Gillum looked for homes that started with a poor rating, then received at least one more within the past year. Among other things, Gillum found that “Nearly all homes that repeatedly received few overall stars — one or two stars — were owned by for-profit corporations,” and that “the lowest-rated homes had an average of 14 deficiencies per facility.” Consistent poor-performers can be found in all 50 states.
Gillum found that one of the reasons homes weren’t improving from year to year is that they’re often given little incentive to improve their ratings unless consumers are actively using Nursing Home Compare to inform their decisions.
Medicare spokeswoman Mary Kahn says a one-star nursing home is not necessarily a terrible facility. Even the lowest-rated homes must still meet baseline Medicare conditions, she says.
“If homes are not motivated to get better, chances are they won’t, and you’ll wind up in homes in poor-quality purgatory,” (Larry Minnix, CEO of American Association of Homes and Services for the Aging) says. “There should be two types of homes: the excellent and the non-existent.”
The Government Accountability Office has followed up its May 2008 report that found a high level of inconsistency in nursing home evaluations (PDF) with a blockbuster sequel: Addressing the Factors Underlying Understatement of Serious Care Problems Requires Sustained CMS and State Commitment (PDF).
In this report, the GAO seeks to figure out exactly what’s causing state inspectors to miss serious violations on at least 15 percent of their surveys. The answers? Bad survey methodology, workforce shortages, inexperienced surveyors, bad survey documentation, odd state practices and, most interestingly, outside pressure from stakeholders like those in the nursing home industry.
The entire report deserves a close review, but for now we’ll settle for a few cherry-picked highlights. Keep in mind that while the federal government sets and enforces standards, much of the process, including hiring, training and review of surveyors, is left up to the discretion of the states. For the report, the GAO surveyed 98 percent of state agency directors (Pennsylvania’s Deputy Secretary for Quality Assurance asked that state’s surveyors not respond) and 61 percent of eligible nursing home surveyors.
Practices vary, as do the reasons behind them
“Forty percent of surveyors in five states and four directors reported that their state had at least one practice not to cite certain deficiencies.”
“… over 40 percent of surveyors in four states reported that their states’ informal dispute resolution processes favored concerns of nursing home operators over resident welfare.”
“… directors from seven states reported that pressure from the industry or legislators may have compromised the nursing home survey process, and two directors reported that CMS’s support is needed to deal with such pressure.”
“If surveyors perceive that certain deficiencies may not be consistently upheld or enforced, they may choose not to cite them.”
“Fifty-four percent of surveyors nationwide reported on our questionnaire that supervisors at least sometimes removed the deficiency that was cited, and 53 percent of surveyors noted that supervisors at least sometimes changed the scope and severity level of cited deficiencies. Of the surveyors, who reported that supervisors sometimes removed deficiencies, 13 percent reported that supervisors always or frequently removed deficiencies — including 12 states with 20 percent or more of their surveyors reporting that deficiencies were removed.”
The survey – the length and complexity of which was cited as a contributor to incorrect deficiency reporting – includes 200 standards grouped into 15 categories, which are then rated based on a scope and severity grid.
Scale is always an issue
About 1.5 million Americans live in nursing homes. That’s more than live in Maine, Hawaii, South Dakota or any one of eight other states. Combine this with state budget issues, and you can see how scale would be a serious obstacle to consistency.
“More than two-thirds of state agency directors reported on our questionnaire that staffing posed a problem for completing complaint surveys, and more than half reported that staffing posed a problem for completing standard or revisit surveys. In addition, 46 percent of state agency directors reported that time pressures always, frequently, or sometimes contributed to understatement in their states.”
Does CMS new survey system fix anything?
When the GAO sent out its questionnaires, eight states had begun adopting QIS, which is CMS’ new, and theoretically improved, nursing home survey method (PDF). While the sample size is small, early returns aren’t promising:
There was no consensus among the eight state agency directors who had started implementing the QIS as of November 2008 about how the new survey methodology would affect understatement.44 Three directors reported that the QIS was likely to reduce understatement; three directors reported that it was not likely to reduce understatement; and two directors were unsure or had no opinion… Similarly, there was no evidence that the QIS resulted in higher-quality documentation or improved surveyor efficiency.