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Distributed June 29, 2004
Contact Wendy Lawton

About 600 Words

Vincent Mor and Jacqueline Zinn
Nursing home quality: Public reporting can’t replace public policy

Going public with quality and inspection data isn’t a prescription for better nursing home care. Proactive public policy is required to improve the lives of the estimated 1.6 million elderly in nursing homes in the United States.

Nearly two years ago, the federal government launched a bold experiment to improve nursing home care. The Centers for Medicare and Medicaid Services started publishing newspaper advertisements that rated nursing homes based on quality measures, such as the percentage of residents with infections or bed sores. The government also created a Web site that includes inspection data on thousands of facilities. The campaign was aimed at educating consumers – and forcing nursing homes to compete for their business.

On its face, the campaign makes sense: Go public on quality, improve private care. Trouble is, the federal approach is flawed. Without addressing the underlying causes of poor nursing home performance, the effort could cause an exodus from the worst homes – and leave the remaining residents in the lurch.

Our research of 14,000 nursing homes across the country shows homes that serve high concentrations of poor elderly have more empty beds, employ fewer professional staff, and engage in more problematic practices such as the use of physical restraints. They are also more often cited for health-related deficiencies such as serious bed sores.

So why not let market forces act as intended? Why not steer elderly into better care – and shut these homes down? Because some of the nation’s most vulnerable citizens might wind up getting shuffled to another substandard home.

Homes at greatest risk of closure are largely dependent on funding from Medicaid, the government health program for the poor and disabled. Our research shows that African Americans are four times as likely as whites to live in these low-tier facilities.

The disparity is a function of economics. Medicaid reimbursements to nursing homes are lower than those paid out by Medicare, the federal insurance program for the elderly. Low-tier homes serve few – if any – residents who can pay higher rates through their own insurance or savings. Bottom line: Poor-performing homes don’t have the financial and administrative wherewithal to improve without help.

We argue that Medicaid reimbursements – which pay about two-thirds of the national bill for long-stay nursing home residents – should be increased to improve staffing. Registered nurses, nurse practitioners and other professional staff aren’t cheap. Neither is the training that can prevent falls or infections or encourage physical activity and independence.

More money, however, doesn’t always guarantee better performance.

That’s why state and federal agencies should target quality improvement dollars to these low-tier homes as well as increase regulatory oversight of them. They should create a special fund to support rapid-response interventions when homes show signs of failure. If those measures don’t work, the government should create a fund to boost payments to homes that accept transfers from failing facilities. By having nursing homes pay into the fund, the fund would act like a “risk pool” used in the insurance sector.

Such a system would make it more palatable for facilities with better resources and reputations to accept poor residents – residents who might otherwise end up in a nursing home that isn’t better, financially or clinically, than the one they left.

In addition, we support giving state and county governments the power to take over failing homes. We support more training for nursing home managers. And we support stepped-up community involvement through volunteering.

An estimated 1.6 million American elderly live in nursing homes. The quality of the care they get can be better. The federal government’s initiative to stimulate competition has the right intentions. But we must address nursing home quality at its roots, rather than hope that airing performance statistics in newspaper ads or on the Internet will put an end to poor care. Public reporting can’t stand in for proactive public policy.

Vincent Mor is chair of the Department of Community Health at Brown University in Providence, R.I. Jacqueline Zinn is an associate professor of health care management in the Fox School of Business and Management at Temple University in Philadelphia.

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