Three cheers for government. For the government of George W. Bush and the Republicans. Even as the nation looks to a new administration to give us better health care, it is fitting to salute a last-minute initiative of this administration that marks a chapterlets hope a positive onein the too-often dismal saga of nursing homes.
By now newspaper writers, editors and readers recognize the nursing-home-exposé as a staple of journalism. The exposés began early in the last century, when the federal Department of Labor unearthed horrific tales of neglect and abuse in that eras almshouses, which were the nations repository for impoverished frail elderly people. Decades later, the spotlight shifted to the largely for-private nursing homes. A team led by Ralph Nader published their findings (Old Age, The Last Segregation, 1971). Sen. Frank Moss with Val Halamandaris wrote up the findings of Congressional investigations (Too Old, Too Sick, Too Bad: Nursing Homes in America, 1977). Decades of regulations followed. Those regulations closed the fire-trap buildings, required minimal staff training, and instituted ombudsmen to hear complaints. Subsequent rules ended the too-often cavalier restraints (chemical and physical) that subdued residents. The piling up of regulations ensured a far more bureaucratic operation, with reams of consultants advising on compliance with the myriad required forms. The regulations, though, did not guarantee what any family would describe as quality care.
The dilemma of raising quality in a private-sector industry has stymied government regulators. On the one hand, the government has promulgated regulations upon regulations. On the other hand, the industry has argued, persuasively, that there were some regulationsparticularly for staffingthat some facilities could not meet, particularly within the low reimbursements set by state Medicaid offices. The government could of course sanction nursing homes, but piling fines onto a facility near bankruptcy rarely improved care. As for closing a deficient nursing home, regulators understood the sequelae. If you close a restaurant that fails health and safety standards, patrons go somewhere else. Closing a nursing home leaves its residents bereft, with few options if communities have low nursing home vacancy rates. It also leaves staff with pink slips. Owners (as well as families and staff) have made their voices heard in state capitols: few homes ever close because of poor care.
So the dilemma is real. How do you improve the quality of care in a for-profit industry whose customers are, at best, distraught families, wondering what to do with relatives who need more care and oversight than they can give, and, at worst, confused ailing, and vulnerable people? In instances (a great many of them), where state Medicaid offices assume the costs of payment, the ultimate customer is a state conflicted between two goals: better care, and lower costs. Generally one arm of the state, often the Department of Health, oversees care, while the budget office oversees costs.
If the sunlight of public scrutiny can improve government, maybe Justice Louis Brandeiss wisdom can apply to nursing homes. At least that is the premise behind the latest initiative of the federal government.
The government rated 16,000 nursing homes, using a complex multi-category formula weighted toward staffing (facilities have objected to the weighting). Now, thanks to the Internet, that rating is truly public. Click on to www.medicare.gov/nhcompare. Anyone can check the homes in their cities. Five stars are best; one star marks dismal.
This will not solve the dilemma of substandard care. Only 33 facilities in the nation scored highest in all the categories. USA Today (Dec. 18, 2008) rated Louisiana, Georgia, Virginia, Tennessee and Ohio as the worst states: from 30 to 40% of facilities rated one star. In some communities, families will have few choices: they may end up in a one-star facility by default.
But ultimately, given a choice, families should gravitate to the better facilities. And, if only to capture market share, those deficient facilities should improve.
Ratings happen regularly. In a few years, the nation should know whether sunlight made a difference.
Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email firstname.lastname@example.org.
From The Progressive Populist, Feb. 1, 2009
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