Robert G Kramer wrote an interesting and blunt article for Health Affairs blog. Below are some excerpts.
The US long-term care system, particularly in skilled nursing facilities, has been exposed as deeply flawed, chronically underfunded, and in need of reform. The sector now faces the scrutiny of Congress, as well as policy makers and regulators in every state of the nation. We are in a historic moment, presenting both an immense challenge—and a huge opportunity—to improve outcomes and quality of life for more than a million nursing home residents and more than a million frontline workers who care for them every day. But this moment will not last.
In the coming weeks and months, advocates will push for a wide variety of reforms; most have merit. While policy makers are focused on the sector, it is crucial that advocates from all corners see beyond traditional silos, listen to each other, and compromise. Failure to do so will likely lead to simplistic, fatally flawed quick fixes, or the favoring of one remedy over another. A multifaceted solution is needed. Skilled nursing is complex. Both advocates and policy makers must therefore dispense with out-of-date assumptions, acknowledge our problems, and align the many players involved, if we’re to achieve what we truly desire for all Americans: a system that works.
The Problems We Have To Acknowledge
Society undervalues the work that is done in the skilled nursing setting. Frontline care givers often earn little more than minimum wage for extremely challenging and important work. This is also reflected in chronic underfunding of skilled nursing, a reality that underlies many of the more visible problems in nursing homes across the country.
Recent stories on the Nursing Home 5-Star Rating System make clear the need to strengthen the system so that the ratings are meaningful for consumers and not misleading. In addition, we don’t know what, or how, to measure for quality of life. Existing metrics, which largely focus on physical care needs and process, do very little to help us understand quality from a resident’s perspective. Metrics must hold operators accountable both for quality of care and quality of life.
Revenues and costs are hidden from view in many of our skilled nursing chains. Policy makers, regulators, and payers, both public and private, lack confidence that financials truly reflect profit margins. How can the industry expect increased funding without delivering transparency into where the money ends up going?
Skilled nursing is still stuck in the old fee-for-service curative health model in which nursing homes are incentivized to send long-stay residents to the hospital. That’s a perverse incentive. We should be incentivizing nursing homes to deliver person-centered, whole-person care, and to keep residents out of the hospital. We must also stop subsidizing shortfalls on the care of Medicaid residents with the profit margins on short-stay Medicare residents. Reimbursement currently drives what type of care is delivered, and in what setting. We have a siloed and uncoordinated maze as a result.
Our regulatory system often burdens the better providers with process paperwork that is unnecessary. The system regularly fails to help poorer performers to improve and is too slow to remove those unwilling or unable to improve.
Our nursing home infrastructure is old and out of date. Fifty-one percent of our nursing home facilities in metropolitan areas are more than 40 years of age. Seventy-two percent are 30 years of age or older. They’re functionally obsolete in that they weren’t built for the very frail, medically complex residents of today. They certainly weren’t built, as we have painfully learned, for infection prevention and control.
Research, such as this May 2020 AARP study, reveals that we are experiencing a collapse in the availability of traditionally unpaid family caregivers. In 2010, there were seven potential caregivers between the ages of 45 and 64, to every 80-plus year old likely to need care. By 2030, there will only be four. As life expectancies increase, and fewer of those in need have family to help them, demand for caregiving services will explode and the cost of such services will soar.
We must address consistently poor performers, either to improve them or to actually get them out of the business, and we must prevent gaming of the system. But there’s no evidence that simply ratcheting up the degree of regulation and enforcement will lead to better outcomes.
We do need increased transparency and accountability. This will help address a major credibility issue for providers, whose claims that their overall margins are too thin to allow additional investment in staff ring hollow without evidence. Government payers are right to demand visibility to ensure dollars go directly to services, rather than into corporate coffers.
Tie Funding To Improved Wages And Accountability
Tie increased funding to improved wages, benefits, and training for frontline staff and addressing gaps in infection prevention and registered nurse coverage. This investment must be paired with meaningful transparency and accountability across providers’ ownership structures and finances. Care workers comprise the fastest-growing labor force in the US today. They also have some of the highest turnover rates in the country. Growing their wages will help to reduce turnover and thereby improve care.
Regulators must shift from punishment focused on failure to follow process to effective accountability for value-based, outcomes-driven care. This overhaul must address measures of resident well-being along with quality of care and include resident and staff satisfaction measures. The framework must incentivize improvement while efficiently removing chronic bad performers.
Household And Neighborhood Models
Use regulation and funding to promote household or neighborhood models that use consistent staffing and even universal staffing. As we have seen in studies of the Green House model during the pandemic, these models perform better in both infection control and prevention, and resident/staff satisfaction.
Integrated Medicaid And Medicare Funding
To the maximum extent possible, integrate Medicaid and Medicare funding and care delivery for those that are dually eligible. We should focus on quality-of-life outcomes, chronic disease management, and palliative care versus the current curative care approach. Integration of relevant data and data flows is also essential, together with encouraging an integrated, interdisciplinary care team approach driven by resident goals.
The author is a member of the Ziegler Healthcare Advisory Board, Sentrics Advisory Board, and Edenbridge Health Advisory Board.