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tv   Brookings Institution Hosts Discussion on U.S. Nursing Home Facilities  CSPAN  December 16, 2016 1:29am-2:27am EST

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amendments that were sent to the states for ratification. and ten of those 12 were ratified by the states. >> christine blackerbee and jennifer johnson take a tour of the national archives exhibit marking the 225th anniversary of the ratification of the bifl rights on december 15th, 1791. for our complete schedule, go to c-span.org. next, a discussion about the nation's nursing home facilities and the system used to rate them. from the brookings institution, this is a little less than an hour. >> good afternoon. i am niam yaraghi from the center for technology innovation at brookings. i'd like to welcome you all to
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our program on evaluating and improving the nursing homes rating system. nearly 2 million americans reside in more than 15,000 nursing homes all around the united states. medicaid alone spends more than $140 billion on the services provided in these nursing homes. given that, i think it is very important for patients, their families and caregivers to have a thorough understanding of the quality of the services provided in the nursing homes. over the past few years, centers for medicare and medicaid has done a phenomenal job in identifying quality metrics, collecting relevant data, kraeths aggregate measures and then reporting them to the public. these efforts has resulted in services such as nursing home website which provide unprecedented data about the performance of the nursing homes in a very easy to understand format of five-star ratings like
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hotels, nursing homes are now being rated between one to five stars depending on the on-site inspections done independently by cms auditors and two self-reported domains of quality measures and staffing metrics. the percentage of the nursing homes who obtained five-star overall rating as a result of their self-reported measures has continuously increased from 11% in 2009 to almost 25% in 2003. so in collaboration with the university of conkornnecticut, conducted a research to see if -- self-reported ratings are neither associated with the
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on-site inspections in the same year nor the year after. moreover, patient reported complaints gathered by independent third parties are not predicted by the overall ratings who could potentially be inflated but rather are very precisely predicted by on-site inspections which cannot be predicted. overall, we estimate at least 6% of the nursing homes in california, which is the state that we study, are likely inflating their self-reported measures. now i have to say it is a very small percentage. however, even the importance of these ratings would believe there is still room for improvement. we have a terrific panel of experts here today to discuss the current rating system and the strategies to improve it.
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but before we start a discussion, i would like to mention that the support for this research was generously provided by national institute for health care management. so i'm pleased to introduce cristina boccuti who san associate director of the program on medicare policy at the kaiser family foundation. >> joe demattos is the president and ceo of health facilities association of maryland, which is the oldest and largest long-term associated in the state representing skilled nursing, subacute facilities, assisting living programs and continuing care retirement
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communities. he just returned from hawaii. toby edelman is senior policy attorney at centers for medicare advocacy. she has been representing older people in long-term facilities since 1977. she provides training research, policy analysis, consultation and litigation support relating to nursing homes and other long-term facilities. and finally, edward mortimore is technical director at the division of nursing homes as the centers for medicare and medicaid services. he helped launch medicare -- and has also led the development of the five-star quality rating system at nursing homes compare website. he's worked with academic researchers, program evaluators and the press in developing methods to use cms data to monitor changes in the u.s. population of nursing home
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residents as well as to evaluate the effectiveness of the cms regulatory oversight of those nursing homes. so cristina, you looked at the star ratings on nursing homes. one of the interesting things you reported in your research was the fact the states that have higher proportions of low-income seniors tend to also have higher proportions of lower rated nursing homes. why do you think that is? >> well, yes, we did have that find, and i think it relates to the geography of the types of nursing homes that are in those states. so we found, for example, that for-profit nursing homes tended to have lower -- larger shares of for-profit nursing homes had
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lower ratings than the not for profit nursing homes, which are -- so the for-profits are often located in areas where senior seniors -- higher rates of seniors in poverty. also smaller nursing homes had higher ratings. tended to have higher ratings than larger nursing homes and we found that to be the case both for for-profits and not for profits but we've also found that larger nursing homes are more often in areas with lower income seniors. so those would be some of the findings that relate to the income. i would also point out that state comparisons, and that's partly what that was. state comparisons have an issue in the methodology of these state ratings in that the health inspection rating, which is one that is not self-reported, as
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you've been pointing out. the state ratings are curved, essentially so that in every state, it has to be that i think the bottom -- i wrote this down. the top 10% get five-star. the bottom 20% get one star and the remaining are evenly distributed. so that's a constant. so comparing state to state on just those measures is really -- you'll get the same thing. so what it does highlight is that the differences between states and areas even if you -- however it is, is really a factor of the other two measures that are self-reported. so i think that's an important thing to think about. but it also means that the differences could be much wider if you look across the states because, say, for instance, you had one state where let's just say all the nursing homes are
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fantastic. but they still have to show that the bottom, you know, the bottom 40% of only going to have one or two stars, even if they're all very good. so that kind of opens up the door to, well, what is really happening when you look nationally. so i think it may be interesting if we saw both. like the state, how they are relative to others in the state because there are reasons why it's just they are a state relative norms in that's what you're looking for. people aren't comparing mostly whether they'll go to a nursing home in alabama or vermont. they're looking in their area so you look at a relative in their area but we don't know about it nationally very well. and so i always think about what else we could learn if we looked at it both ways. so that gets to that geographic issue. and i think i'll stop there. of course, i have several more
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points to make. maybe that will come as we continue. >> thank you. the cms on-site inspections are like the super bowl for nursing homes. could you provide the perspective of the nursing homes about the ratings and the importance of the ratings for the nursing homes. >> the first thing i would say is that the cms rating system has been incredibly valuable to both consumers and people working in partnership in the health care continuum. so consumers in maryland and all across the country go to nursing home compare and look at those rating systems and compare skilled nursing and rehab centers. when hospitals on the one end of a continuum or home health care decide with whom to partner within the local community, like in baltimore, they put value in those five-star rating systems. so i think having the system is
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a major step forward. generally speaking, in terms of interest rating system, of course, none of them are perfect and that's true of this one as well. one of the challenges is that it is an inherently curved system, the percentages of one-star versus five-star are statistically allocated. that's sort of just a design, a necessary design flaw. complaint driven inspections are a big deal in skilled rehab centers. they're not prevalent in other settings. and most other settings, all of the quality measures are self-reported. they're not based on annual inspections, whether it's a physician's office or medical center. so annual inspections are a big deal in skills nursing and rehab centers. a couple ever points that are interesting about maryland specifically when you talk about not the 1600 skilled nursing
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rehab centers part of this but the nearly 16,000 across the country. you compare them with maryland as a snapshot. so interestingly, maryland has a very, very diverse skilled nursing and rehab community. about 233 centers, everything from genesis health care which is the largest provider in the united states, which has almost 40 centers in maryland, down to second, third generation women owned center. what's interesting in maryland is the number one largest center in terms of number of beds and number of days serve in all of maryland is the community just a little down the road here in montgomery county. and it's a not for profit that operates and sustains itself as running as a for profit in terms of its business enterprise. and the number two largest skilled nursing and rehab center in maryland is still ameris in towson. a nonfor profit owned by the
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sisters of mercy. what's the case in maryland with regard to skilled nursing rehab centers, it's a very diverse group of providers. what you'll find is whether they are for profit or non-profit, that the -- they really are a safety net for folks on medicaid. relative to the paper, a couple of observations. it was great to read and it's an incredible step forward. and anything that can push the pause button and get us thinking on how we can improve the rating system is a very good thing. it's interesting that there's this distinction in the paper between self-reported data versus the survey. the reality is you probably need both in an ideal system going forward and here's why. the survey, you can have a fantastic center, five-star, fantastic, great center, and they could have one place where they really drop the ball out of
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one resident out of 300 residents. and they don't even have to drop the ball on that one resident in a catastrophic, damaging sort of way. it could be a number of minor things that happened with that one resident. and as a result of that, a survey can massively impact a center and it's based, of course, on that inspection and on that one individual potentially. i'll give you an example of that in maryland. up until recently, we had a center amongst the best in maryland by both state and federal ratings systems. a five-star center. they received 26 inconsequential, no life harms, very low-level deficiencies in their annual inspection. 26 of them. four of the deficiencies were for a single malfunctioning wheelchair. as a result of that survey, that center went from a five-star
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center to a one-star center. and it's now a two-star center. but it's amongst the best in maryland. so again, the survey can be valuable and powerful. now it's interesting, if i'm a consumer, i think the survey is valuable for the reasons i've just said, but again, it can go either way based on the results of one consumer. the self-reported data with regard to quality or staffing. staffing is a little less of an issue now that cms is requiring payroll journal reporting where they have to report actual payroll data. if i'm a consumer or hospital partner, i want to have survey data. i want to have payroll data and i want to have quality data. and the value of the quality data and the payroll data is that unlike the survey, it's not swayed by one consumer experience. it's cumulative for the entire, you know, for the entire center. just one last point before i hand it off and we get further
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into the discussion. the notion that we could, as a nation, rely more on survey data and less on self-reported data, as we extend the findings of this study and look deeper across the country, which i think we need to do, could be problematic. because as you go from state to state, the variablity on state survey capacity and the correlation between inspection surveys and ratings could be incredibly more problematic. so with that, i, too, have more to add, but let's open it up and take it down the path. >> thank you very much. toby, you've been doing research in nursing homes since before i was even born. >> that's a compliment.
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>> [ inaudible ]. >> he meant it in a positive way. >> okay. >> it's actually the thing that she said to me in a telephone conversation before. so i hope she knows that i'm meaning it as a compliment. >> it's fine. >> you have written extensively on special focus facilities, and the fact that their ratings are generally lower than the others, when it comes to special focus facilities, is there any challenges in the rating systems, and what do you think should be done about it? >> okay. well, thank you. as an advocate for residents for 40 years almost, i was really pleased to read this paper documenting the inflation of the self-reported domains on nursing home compare, staffing and quality measures. the paper confirmed what a number of us have found and documented in our own work over the years that facilities boost their overall ratings by recording information on staffing and assessment and as a result, they get very high star
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ratings. high scores. because cms doesn't audit the information that it places on nursing home compare, just reports what is self-reported by facilities, facilities, i think, make themselves look better than they actually are. there's often very little correlation between what the surveyors document in their unau unannounced public surveys n what facilities self-report. so we've been thinking about this on an anec doetsal ads hock basis and i decided to look more systematically. in december 2011, five years ago, i looked at the special focus facilities. these are a very small subset of the one-star facilities. the one-star in survey. they are chosen by states and cms working together and there may be one, possibly two in a state. so these are really very selective, very poor, by definition, among the most poorly performing facilities in the country.
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in 2011, i looked at 47 facilities. 47 of them. 46 received one star in the survey. that's what you'd expect. but 25 of the 46, more than half, had four of five stars in staffing. and 17 of them more than one-third, had four or five stars in the quality measures. even more significant, i think, the high scores on the self-reported data boosted facilities overall star ratings. so 18 of them, 38%, had overall scores of two stars. and one even had a score of three stars because it self-reported good information on staffing and quality measures. in january 2013, i redid this work and got similar results. more than one-third of the facilities had four or five stars in staffing and quality. public attention really came to this issue in august 2014. there was a front page article in "the new york times" called medicare star ratings allow
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nursing homes to game the system. and katie thomas reported nearly two-thirds of the 50 nursing homes on the special focus facility list reported staffing and quality measures of four and five stars. same thing we had found in our work. cms and the white house immediately announced changes that they would reduce the reliance and rating system on self-reported information and make additional improvements. and they did. but the problems have continued. when the clinton administration first started nursing home compare in 1998, and in those early years, the information apparently didn't influence people who were looking for nursing homes for a placement for a relative. but this fall, i read a research article that indicated that once the five-star rating system went in eight years ago, that seemed to influence placement decisions. and it found that admission to one-star facilities had declined by 8% and admissions to -- one-star flts had declined and
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admissions to five-star facilities had increased by 6%. i did a third analysis of special focus facilities. and this time i looked at 42 of them. 16 that were newly added and 26 that hadn't improved. nearly 45% of them, 19 of the 42 facilities, reported overall scores of two. in other words, they boosted themselves out of the one-star category that people tried to avoid when looking for a facility and got two stars. they had gotten these two stars because of staffing and quality measures. at the same time, i was doing this work, i read an article in the trade press indkating that 96% of the facilities that had five stars for their overall rating in the seven years that they looked at, all seven years, 96% of them had their high scores because of self-reported measures, not because of the surveys.
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so the facilities at the top of the scale were able to get themselves a five-star rating, which is where people are looking for facilities, presumably increasing their admissions by reporting the data. so i think we're very concerned about the self-reported nature of the staffing and quality measures. especially when cms has known for years that these data are pretty inaccurate. >> thank you. >> i have some recommendations for later as well. >> thank you. edward, you are the architect of the system that we are talking about. and you've been involved since the very beginning. we are going to have very major changes in the overall health care policy in the united states going forward. so i would like to know, how the nursing home rating system changed since its inceptions to date and how it's going to change as we go forward. >> great, thank you, niam.
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thank you for having me and for the paper that you so carefully put together that i think offers a helpful and critical analysis of some important dimensions. so nursing home compare has evolved a lot since we put it together. really as a simple information system to help people find nursing homes in their area. that was its origin. pretty simple. we started adding more and more information to it to be even more helpful. eventually got so cumbersome that we were asked to create a ratings system to help synthesize the information on the site. i think that's been very helpful, but certainly the needs of the site and demands of the site have evolved. fra frankly, probably a little faster than we anticipated. we designed a way to synthesize the vast amount of complicated information to help consumers in
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their search and it is -- i think it's important to remember we've designed it and we still consider it to be first and foremost consumer information site. but we recognize that it's evofld and whether we intended it to be or not it's used as a report card. we know that managed care organizations, accountable care organizations, banks, insurance companies, hud, all use the ratings system in different ways and, frankly, different levels of involvement, i guess i should say, to make their decisions about who gets what contracts, who gets what loans and who can get a mortgage guarantee, for example. so those are some of the issues. that's probably the major issue we were facing going forward is how to develop the system to be responsive to those uses that have really freighted it with
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consequences we didn't intend. that creates a feedback loop. we've all heard examples and your paper amply demonstrates that with the incentives for high scores are out there and that has a direct impact on reporting. i don't think there's any question about that. we've seen it. we recognize that. i should point out we're doing a number of things. we have done a number of things and more things are planned to try to address that. partly in response to the katie thomas article in "the times." we were able to implement some things we were planning for a while. and that was bring in quality measures that were not explicitly self-reported. and i think this is helpful for everybody, for providers and consumers alike. because what it did was add a lot of new information, particularly addressing areas of
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care that, frankly, we were a little bit short on, particularly rehab short stay outcomes of care. we added several measures that were not based on self-report but rather based on claims of things like hospital readmissions, emergency department visits, successful discharge. i think there's a consensus those are important outcomes of care. and they have the advantage of not being self-reported. frankly also not burdening providers as well since they were building those from claims that have already been submitted. we are also -- we've moved as i think many of you know, we've recently implemented a payroll base staffing system. that's something that's been planned -- cms had developed a number of years ago, but in the fall of 2014, received funding from congress to implement. that's a system that allows nursing homes to directly report
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staffing levels at the staff person level for each day. that will open up a realm of opportunities for better measures, measures that will be helpful to providers. so we'll be able to look at daily staffing, things like turnover. we'll have it at the person level. we're not identifying the names of people. we don't know how much they make but we do know, we can distinguish the individuals by i.d. we can look at turnover and tenure. we can look at staffing by day. and i -- our intention is to provide those reports back to providers and to consumers to help both understand the dynamics of staffing and resident census and resident care needs and their intermix. so we are hopeful that is and that will be subject to audits. so we're actually developing an audit process right now with an accounting firm and actuaryial
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firm. the data collection piece is in place. and i think we have about 94% of nursing homes reporting data through that already in the first quarter. still have to evaluate the quality of the data. there is a learning curve. it is a significant effort for nursing homes to report that data, we acknowledge. but the audit process will be in place probably within the next year. so we think that's a significant step forward. >> thank you very much. my next question is to all of the members of the panel. and i would like to know each one of you from your own perspective, what do you think is the most important challenge when it comes to the current rating system and overall evaluation of the nursing homes and of what do you think should be done in long term future to address those challenges. so any one of you -- >> i'll jump in on that. so a couple of -- first, a
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couple of quick observations. so in terms of -- i'm actually not surprised by toby's data with regard to special focus facilities, right? special focus facilities, these one or two skilled nursing rehab centers in each state across the country, these are centers that are identified by state and federal regulators. they're not even going to make it wholly to number one. they're substandard centers, and there's an intervention put in place. and so when you look at that intervention that's put in place, i don't think, and i've been in one of these centers, like three weeks ago, i was in one of these centers. i don't think it's unrealistic to self-report much higher staffing level and much higher quality measures in those centers because they are basically responding to a triage critical event of the center. the center may not survive. it may no longer be a federally certified center unless appropriate resources are brought to bear and raise it up.
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so i'm actually not surprised by that. with regard to nursing home compare and in 1998 versus now, you have to remember that in 1998, we were still living in a time when people were often admitted to a skilled nursing and rehab center in relatively good health and driven there by a family member, right? it was a totally drchts lly dif. the vast majority of people admitted both for short-term care for rehab, congestive heart failure event, kidneys, orthopedic event or for long-term care, they are admitted by a hospital partner, right? they are driven there by ambulance. and so many, many of the services that 25 years ago were provided only in hospitals across the country are now both in terms of long-term care and
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in rehabilitative care provided for and in the skilled nursing and rehab centers. and that's why, as you mentioned, that the five-star rating system is so important because many people are using it as a proxy. hospitals are using as a proxy, should i send my long-term care patient to skilled nursing rehab center "a" with a three-star rating versus "b," versus a five-star rating. one more thing before we get to the challenge because the challenge is related. all of these issues of staffing. these are all issues that come up during the inspection and the annual surveys. so if there's a disconnect between self-reported staffing and then staffing as part of the survey process, this is something that is inspected during the annual inspection in the survey process. and we can look at this disconnect. again, moving forward because the payroll journal and this is an audible -- this will be the last of an issue.
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finally on self-reporting, you know, they are 75 mds measures of quality, each with 16 subcategories. and in order for a foreign entity to intentionally manipulate that reporting, in order to raise the five-star numbers, as an intentional measure, would certainly set off a lot of different alarms at various oigs, both state and federal if it were an issue. so it would require an incredible level of sophistication. now all of that connected to the big challenge going forward, i think probably the biggest challenge going forward work with our cms partners and others is recognizing that -- what skilled nursing rehab centers are today. they are folks that are providing services, teams that are providing services that 25 years ago were largely provided for in hospitals, right? and so they have very high acuity patients. and figuring out how the rating
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system can go forward and recognize the difference between -- or the connections between acuity and medicaid versus medicare, right? because that center that i talked about in baltimore a few moments ago that went from a five-star to a one-star, in order for that center to continue to be viable, they have to be able to partner with their other partners across the continu continuum. they'll want a three-star review. but in order for that building to be a resource for marylanders in need in baltimore, they're going to have to continue to take elders that are incredibly challenging, clinically challenging and on medicaid and so going forward, in a best possible world with cms five-star rating system, maybe some -- maybe some evolution on their recognition that we really are serving sort of different systems of medicare/medicaid to
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ensure those systems are still in place for people in need in the systems. so that would be my wish going forward on the rating system. >> thank you. >> well, i have concerns about putting all of our hopes and dreams on the five-star rating system because this is pretty much a market-based approach. we'll give people information and let them choose facilities. and i don't think that's sufficient. i think we need to improve and strengthen the public regulatory enforcement system to make sure that facilities aren't actually meeting standards. and as joe said, a lot of residents look very different today from the way they looked in 1998. we just missed the boat with cms on the revised requirements of participation for nursing homes first big revision in 25 years is that we didn't change the staffing standard. we set the same standard we had in 1998, which is a registered nurse on the day shift, licensed nurses around the clock and
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otherwise sufficient staff to meet residents' needs. and very few, even though we have a report from cms from 2001 the whole world relies on saying that 90% of facilities don't have enough staffing, the regulatory system almost never cites staffing as a deficiency because the standard is too vague. and so i think we need to both increase the staffing in nursing homes dramatically. there's legislation that congresswoman janet schakowsky had for many years, put a nurse in the nursing home like there really need to be registered nurses in nursing homes around the clock. that hasn't passed and doesn't seem likely to pass in the immediate future. but we need better staffing, and i think better enforcement. -- to get better care for people because many people really don't have any family. there's nobody that they have who can advocate for them. and so the public purpose and
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what the nursing home reform law says from '87 is the secretary has to assure that the standards and their enforcement are adequate to protect residents' health, safety, welfare and rights. there's an important public role the regulatory system has to play. >> and in fact, i'll add that one-third of the counties in the u.s., we found, have three or lower stars. so that sort of highlights what is the federal role when you have these minimum standards? how can we boost the lower ones? it's like trying to get into the five-star. well, what about those that aren't trying because they don't even have competitors in the -- so they're at the one to three-star ratings in one-third of the u.s. counties. so i think there is something about the federal role and how there is an opportunity to boost up the quality for, really, i think we have to recognize, you
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talked about the acuity level. but even 30 years ago, these are the most frail, vulnerable populations that we have now. and so standards, and you brought up the standard of staffing, and that was something i wanted to bring up because i was kind of shocked to learn that it's a one registered nurse for eight hours. this is just the minimum. one registered nurse for eight hours daily, regardless of the size of the nursing home. now many states are requiring more. so the states have taken it on to say that that's not really required. but the federal medicare and medicaid certification requirement borequire ments do not require more than that. a challenge beyond the star ratings has to do with what is being done for the low, you know -- not just the focus ones
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that you bring up, but the two-star nursing homes and the people that don't have any choice. in fact, there could be a five-star nursing home but they can't get into it, right? it's full. it's the only one in the county. they can't get into it. where are we with the people that are looking for the other ones? and also people can't move. a lot of times you are in one and you find out it's, whatever. do they have family that can pack them up? how disruptive it is to move to another nursing home. >> all of these are really good points. we cannot expect a free market to operate as long as we do not have choice. and when it comes to the residents of the nursing homes, as was mentioned in the panel, many of them really neither have information nor choice. therefore, i think it's more important to think about the role of government in increasing the quality and basically
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advocating for those people who don't have a voice. well, i think we have some time to get some questions from the audience, and there would be a microphone coming to you. please. >> i don't know if this is -- am i coming through on the mike? >> yes. >> i don't know if this is just a crank issue, and feel free to pass it by. last january, i had an accident. i went to work, and i couldn't come home. wound up in the hospital. had three surgeries. was in rehab for orthopedic stuff. and one of the things that made me absolutely crazy was that on weekends, certain types of staff weren't available. when you're in a rehab facility, when you're in a skilled nursing facility, there are no saturdays and sundays. except maybe for the menu when they are trying to impress the visitors, and that's another issue, but i was shocked that there were so many things that i
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had to pay for out of pocket because they weren't provided on a regular basis. i needed a physician to come in and see me on a saturday because i had surgery on a friday. and it took six hours to get a doctor there and cost me $400 out of pocket. so is there -- are there any regulations about consistency? also when they change shifts. you can't get any medication when they change shifts for about two hours in rehab facilities. so maybe this is just a crank issue, but it's for the person who has been in a rehab facility, the unavailability of staff, the inconsistency of availability of staff is a major issue. >> thank you. >> yeah, so, no, i don't think it's crank. it's a fair comment. you know, we've -- i'm glad you're better. that's the most important thing. we've had -- i've had family in
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skilled nursing and rehab centers as recently as a few months ago. and there's no doubt that staffing is not the same in a skilled nursing and rehab center on a weekend as it is in a hospital. there's just no doubt. especially if you are there for, you know, an intense orthopedic rehab. the good news is that we do have, in maryland and across the country, skilled nursing and rehab centers that do intense rehab, more intensely, more focused than in other settings and get folks in and out of the centers quicker than we used to. the average length of stay for medicare resident in maryland is 28 days. it's about the same as the national average. so that's the good part of the equation. sounds like you were on a medicare qualified stay, and so -- or private insurance.
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either through medicare qualified stay or private insurance, the doctor's visit counts as an out of office visit so there's a co-pay for that visit, and that's one of the things that's challenging for americans all across the country. so in maryland, we have a law that says that you have to inform a patient when they are going to a skilled nursing and rehab center of their status which we help to advocate for in maryland so that the patient knows that if they are on private insurance or on their three-day qualifying hospital stay that all of those visits, you know, they have -- they are all individual co-pays. and they are going to be paying for that eventually. on the subject of staffing, every state, thank goodness, has higher standards than -- most states. not all states. maryland has much higher standards in terms of rn staffing than is the federal minimum. in terms of physicians, i think there's a trend across the country, and i've been fortunate
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to visit a number of skilled rehab and nursing centers across the country. i think there's a trend for these centers to hire and employ their physicians. genesis health case, the largest company i mentioned before, they had 500 directly employed physicians, future care health care maryland has their own higher -- directly hired physicians. and i think there's also a trend to hire at a minimum level rns and to hire more nurse practitioners. so i think that's a trend as well. one last point on staffing. there needs to be a federal push and a marketplace push. and the reality is that in maryland now, because we have such a competitive environment, maybe it can be a snapshot for the rest of the country. the marketplace is demanding more rns and more nurse practitioners because, again, your hospital might prefer to partner with me if i'm directly
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employing physicians and nurse practitioners than perhaps you who are employing directly rns and lpns, right? so the marketplace -- >> i think another reason that nursing homes might start having more registered nurses or nurse practitioners is that there's tremendous concern in public policy about re-admissions. re-admissions to hospitals, to nursing homes, and there are certain things based on scope of practice laws that lpns and certainly nurse aids can't do. if there's not a registered nurse who is in the nursing home, who is able to handle problems, they have to send people to the hospital because they can't deal with the problems themselves if they're an lpn. so that's -- >> that's the driver. that is absolutely the -- >> that's the driver. but we could have put it in federal law. >> [ inaudible ]. >> yeah, well, that's right. there was an inspector general's
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report several years ago about adverse events in nursing facilities. they never looked at that before. it was always a hospital concern. n the rate was higher in nursing homes. and what they found in the average of 15.5 days, that's how long it took, there were tremendous medication errors, falls. the nursing staff didn't respond quickly enough or didn't identify the problems. many rehospitalizations and many deaths that had not been anticipated because they were just not sufficient staff to provide care. and, you know, we know, i understand nursing homes say they don't get enough under medicaid, whether they do or not is a debatable point, depends upon the state, but the medicaid rates are extremely high. the medicare people in 15 1/2 days not getting good care. that's really inexcusable. >> thank you. let's get a question from the other side of the room. the gentleman there.
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>> ben harter with u.s. news and world report. i oversee our public reporting program, including best nursing homes ratings which we have used data for years on and our hospital rankings. i appreciated mr. dimatos bringing up the question of rehabilitation intensity. i want to develop that theme for a moment. you mentioned the important investigation "the new york times" did a couple of years popping another important investigation led by "the wall street journal" last year that looked at utilization of rehabilitation and at the patient level, looking at claims as you mentioned. the patient level, how much rehabilitation was administered teach patient. and one of the most striking observations that those journalists made was that there are two clinically implausible spikes in the utilization of rehabilitation therapy at the points at which reimbursement is
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maximized for nursing home facilities. and supported by a lot of anecdotal evidence and commentary by former employees and current anon myselfanonomiz employees. concern about the clinical appropriateness of that care that was being delivered. and following that publication of that investigation, cms did release -- it has not, to my knowledge, been worked into the plans for the nursing home ratings yet, but did release a facility level data set that identified essentially the percentage of patients who are at these high -- very financially valuable junctures in their care for the nursing homes. the national average, and, in fact, the maryland state average, is that two-thirds of the patients who receive the highest level of rehabilitation rehabilitation care are treated
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within a 10-minute window that maximizes reimbursement. 2 of every 3 patient in the state. it's troubling. clinicians find that truling. even though cms hasn't incorporated this into their ratings, we decided we would. so we have stripped from the fifth star from every home that exceeds a certain percentage of patients falling into this narrow bracket of rehabilitation. pe took a conservative approach our first year. these are ratings released last month. we will probably ratchet that up over time and we think it can provide additional accountability. so i wonder if mr. demattos would like to pond and i wonder if there is any opportunity to include that in your measures going forward. >> you know, so, i think everybody's concerned about
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therapy getting that close to a cap. it gets everybody's attention. i'll leave that part of it at that. i think one of the arguments that a skilled nursing home rehab center would make going forward is that what needs to be figured into the equation is what was the rehospitalization rate that received the maximum number of rehabilitative care verse russ rehospitalization rate of somebody who received maybe a lower end of that care. i think going -- one other thing certainly nationally that skilled nursing centers in the industry is pushing forward to the notion of a bundle payment where the number of hours really don't matter, just the clinical outcomes matter. give me a lump sum, tell me what i'm expected to do clinically on behalf of this patient, allow me to partner with on the one hand
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the hospital and on the other side the home health agency and let me produce a clinical outcome. i think going forward we had been hopeful that that would be a more likely federal model and i think all issues of federal health care policy are sort of now at a pause and we don't know what will be the case. so again, the pretense that i will just reiterate is that it is striking any time you look at data that is that close to a cap. i applaud you looking at that. i think that an industry response would be, yeah, we did that but we want it look what the we satisfied the open to the total system in terms of rehospitalization and better clinical swro clinical outcomes. so i think have you a look at fair data beyond that event and total care of the patient and total clinical outcome for that patient.
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and the third point, now is a question mark, i think as a country will be better served by encouraging partnerships that are clinically driven across settings that says your goal is to focus on getting mary or joe better and it partner with somebody else and there is this much money to do that. don't do that. and hours of care in that kind of a model are much, much less relevant. >> i'll just -- [ inaudible ] >> yeah, yeah, historically, and this compares that nursing home grew out of a regulatory environment, we've been paired agnostic. we do minimal reporting of therapy hours on this site. we've never really looked at therapy, particularly medicare therapy. but it is something we're
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considering. particularly now with the advent of more payroll based data where we can look at therapy across all pairs. it is something worth definitely we would be interested in taking a look at. >> could i just say something about that quickly? >> yes. >> cms is very concerned about this reimbursement issue and is trying to develop a new system because even though there is perspective payment system in medicare, the way this system has worked because of minutes of therapy determining the rates, most residents or facilities are billing at highest rates. so cms is actively involved in making a change. there are numerous follows claims pending against large corporations that have that issue of billing all of their residents or a large portion of their residents at the highest categories. the third concern is something that my office as center for
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care advocacy is the opposite. we have litigation settled by the court in january 2014 saying people are entitled to therapy in nursing homes and home health and out-patient therapy to maintain function, not just to improve function. someone particularly with a chronic condition needs therapy to prevent a slow decline of deterioration, they have a right to therapy. it is hard to get that implemented because of the fear and over utilization of therapy tp so there is overbilling for therapy but we're also concerned about the underbilling of people who aren't getting what they need. >> so i appreciate that discussion as a clinician actually physical therapist times 20 years. i want to delve into the side of the measures related to quality even selfclinician we have used
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based tool for practice so i'm curious why we are slow or what the clael is fhallenge is for u validated measure for the self-report quality tool. >> well, there are a if you reasons. first of all, i think the quality measures are reasonably well validated. i think the challenge has been evolving measures that deal with new populations. so the many of the measures are essentially 20 years old and in more terms of the constructs, so getting back to joe's point, they tend to deal, tend to consider the nursing home population as more homogenius. and really this summer until the 16 measures, vast majority were focused on long stay.
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there is also presence of physical restraint and so those are important pearl harbor urs but they are missing key issues. i think you need to recognize that nursing homes themselves and residents are a much more homogenius population than we have had in historical measure. there are issues around self-report. but i do want to emphasize that nursing homes, quality measures are based on medicare claims and ds, minimum data, a clinical assessment that legally and medically part of the clinical record. and its primary purpose is for resident treatment. it grows out of stuff that the care planning that nursing homes do for all of their residents. these are not aggregated
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measures reported separately outside of the clinical care process. and they deal with, you know, physical functioning and very important clinical outcomes. so i think there are issues with how the ratings have changed overtime. no question. but i think think are well validated clinically, and challenges in sort of how they are used at the nursing home and i think more importantly, sort of in the breadth of measures we are able to offer for the population. >> i think we have to take the other questions off-line. because we are out of time. and i would like it thank our panelists. christina, joe, toby and edward. i appreciate all of you for providing us with our insights and thank you very much for coming out. [ applause ]
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this weekend, c-span cities tour along with our cox communications cable partners will explore the literary life and history of scottsdale, arizona. nicknamed the west's most western town. on book tv on c-span 2, hear about life on route 66. known as america's mother road. route 66 was one of the original u.s. highways between illinois and southern california. in his book, the 66 kid, raised on the mother road, author bob bows bell recalls his life in kingman, arizona, located on route 66. and the many things he observed while helping his father run a ga

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