Transcript Presentation by Toby Edelman (PowerPoint)

CENTER FOR MEDICARE ADVOCACY, INC.
ONTARIO HEALTH
COALITION
March 31, 2009
______________
www.medicareadvocacy.org
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OVERVIEW OF PRESENTATION
 Nursing home industry in USA
 Public oversight of nursing home industry
•
Nursing Home Reform Law (federal law, 1987)
 Nurse staffing
 Tension between market-based and regulatory
approaches to assuring high quality of care and
high quality of life for residents
• Advocates for residents want regulation
• Nursing home industry wants market-based approaches
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NURSING HOME INDUSTRY IN
USA
 Historically, old age homes, county poor
houses
 Industry expanded with introduction of
federal funding (Medicare for old and
disabled people, Medicaid for poor people)
in 1960s
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NURSING HOME INDUSTRY IN
USA
 Change over time, increasing for-profit
ownership
 Now, two-thirds of facilities are for-profit;
one-quarter are not-for-profit; rest are
government-owned
 More than half of facilities nationwide are
owned by chains, often, multi-state chains
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NURSING HOME INDUSTRY IN
USA
 Most nursing homes are free-standing, not
part of hospitals (hospital-based)
• Charlene Harrington, et al, Nursing Facilities,
Staffing, Residents and Facility Deficiencies,
2001 through 2007 (Sep. 2008),
http://www.nccnhr.org/uploads/File/Harrington
_01-07_OSCAR_complete_2008.pdf
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NURSING HOME INDUSTRY IN
USA
 Recent trend: creation of multiple corporations for
a single facility, separating management, property,
etc.
• Joseph E. Casson, et al, “Protecting Nursing Home
Companies: Limiting Liability Through Corporate
Restructuring,” Journal of Health Law, Vol. 36 (Fall
2003),
http://www.proskauer.com/news_publications/publishe
d_articles/content/2003_12_02/_res/id=sa_File/Journal
%20Casson%203.pdf
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NURSING HOME INDUSTRY IN
USA
 Recent trend: take-over of chains by private
equity firms, e.g.,
• Beverly Enterprises –
•
•
Fillmore Capital
Partners
HCR Manor Care – The Carlyle Group
Tandem Health Care – JER Partners and
Formation Capital
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PRIVATE EQUITY FIRMS
 Quality of care declines following take-over
• Charles Duhigg, “At Many Homes, More Profit
and Less Nursing,” The New York Times (Sep.
23, 2007),
http://www.nytimes.com/2007/09/23/business/2
3nursing.html?_r=1&scp=19&sq=Charles%20
Duhigg&st=cse.
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PRIVATE EQUITY FIRMS
 Manor Care CEO was to get $118-186 million
when the private equity firm bought his company
•
The Center for Medicare Advocacy calculated how
many RNs and aides could be hired with the money
•
•
•
•
$118M: 5346 CNAs (19 per Manor Care facility)
$186M: 8427 CNAs (30.3 per Manor Care facility)
$118M: 2198 RNs (7.9 per Manor Care facility)
$186M: 3464 RNS (12.5 per Manor Care facility)
• Center for Medicare Advocacy, “SNF CEO’s Windfall Could
Have Provided More Staff and Services” (July 2007),
http://www.medicareadvocacy.org/Commentary_SNFCEOsWin
dfall.htm
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2001-PRESENT
 Nursing home industry losing ground to
home health and home and communitybased alternatives, including assisted living
 Industry has attempted to shift to higherpaying Medicare beneficiaries
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PUBLIC OVERSIGHT
 State oversight of all facilities under state
licensing law
 State oversight was historically ineffective
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PUBLIC OVERSIGHT
 Federal oversight depends on nursing
facilities’ (generally) voluntary participation
in federal payment programs (Medicare,
Medicaid), resulting in certification
• 99.9% facilities participate in one or both
programs: 3.2% Medicare only, 2.2% Medicaid
only, 94.5% both (Harrington, Table 6, page
17)
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REAGAN ADMINISTRATION
 Considered elimination of “residents’ rights” as
facility condition of participation in
Medicare/Medicaid (never officially proposed;
leaked draft)
 Proposed regulations for surveys, 47 Federal
Register 23,403 (May 27, 1982)
• Less-than-annual surveys
• Self-surveys
• Deemed status for nursing facilities accredited by the
Joint Commission on the Accreditation of Hospitals
(now called Joint Commission)
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CONGRESSIONAL RESPONSE
 Two legislative moratoria preventing
deregulation
 Agreement with Health Care Financing
Administration (HCFA) (as second
moratorium was about to expire) to fund
study by Institute of Medicine (IoM) (part
of National Academy of Sciences)
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INSTITUTE OF MEDICINE (1986)
 Report recommended changes to entire
federal oversight system for nursing homes
• Requirements of Participation for facilities
• Survey process
• Enforcement system
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INSTITUTE OF MEDICINE
 Nurse staffing
•
•
•
•
Recognized nurse staffing as a major factor determining
quality of care and quality of life
But did not recommend specific staffing ratios because
of “the complexities of case mix”
Called for standardized resident assessment data and
empirical studies to determine appropriate staffing
levels
Urged facilities to “place their highest priority on the
recruitment, retention, and support of adequate numbers
of professional nurses” with training in gerontology and
geriatrics
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INSTITUTE OF MEDICINE
 IoM staff challenged staff of National Citizens’
Coalition for Nursing Home Reform (NCCNHR)
to work for enactment of the recommendations as
federal law
 NCCNHR formed Campaign for Quality Care
(CQC) (members were health care professionals,
advocates, nursing home industry) to identify IoM
recommendations that should become law
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CAMPAIGN FOR QUALITY CARE
 CQC met frequently for a year to discuss
IoM recommendations
 Most work was done on Requirements
(based on good provider practices, good
state practices)
 Survey was non-controversial
 Enforcement had least agreement
 Honorary Chair: Actor Kirk Douglas
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NURSING HOME REFORM LAW
(1987)
 Based on IoM recommendations and CQC
 Defined Secretary’s responsibility broadly:
to assure adequate federal standards, and
enforcement of those standards, related to
health, safety, welfare, and rights of
residents
 Addressed Requirements for facilities,
survey, and enforcement
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NURSING HOME REFORM LAW
 Big changes in Requirements for facilities, e.g.,
•
•
•
Nurse aides must be trained and competent before
providing care (half the states did not require any
training in 1987)
Recognition of residents’ quality of life
Facilities must provide care and services so that each
resident attains and maintains his or her highest
practicable level of physical, mental, and psycho-social
well-being
• Not a minimum standard of care
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NURSING HOME REFORM LAW
 Biggest missing piece: nurse staffing
standard
• Reform Law says (regardless of facility size or
acuity of residents)
• an RN on the day shift
• licensed nurses around the clock
• “sufficient staff” to meet residents’ needs
42 U.S.C. §§1395i-3(b)(4)(C)(i), 1396r(b)(4)(C)(i),
Medicare and Medicaid, respectively
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NURSING HOME REFORM LAW
 Survey requirements
• Multi-disciplinary teams
• Surveyors are trained and tested
• Unannounced surveys on 9-15 month schedule
(12-month average)
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NURSING HOME REFORM LAW
 Enforcement
• Range of intermediate sanctions (e.g., civil
•
money penalties, monitors, temporary
management, etc.) must be enacted, but their
use in most situations is permissive, not
mandatory
Requirement to impose more significant
remedies for uncorrected or repeated
deficiencies
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NURSING HOME REFORM LAW
 Requirements for facilities became effective
October 1990
 Federal enforcement regulations, due 1988,
were not issued until 1994
 Implementation of Law has been prolonged,
delayed, and, with respect to enforcement,
ineffective (too tolerant of poor care)
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JULY 1998
 President Clinton’s Nursing Home Initiative (24
points)
 HCFA released report to Congress on
accreditation, regulatory incentives, and nonregulatory quality initiatives
 Senator Grassley (Senate Special Committee on
Aging) began series of hearings on nursing home
issues (enforcement, bankruptcy, staffing, etc.)
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CONGRESS, JULY 1998DECEMBER 2000

Senate Special Committee on Aging held multiple hearings
• “Betrayal: The Quality of Care in California’s Nursing Homes” (July 27-28, 1998),
•
•
•
•
•
•
•
•
http://aging.senate.gov/hearing_detail.cfm?id=276917&
“Residents at Risk: Weaknesses Persist in Nursing Home Complaint Investigation and
Enforcement” (March 22, 1999), http://aging.senate.gov/hearing_detail.cfm?id=272290&
“The Nursing Home Initiative: The Results at Year One” (June 30, 1999),
http://aging.senate.gov/hearing_detail.cfm?id=272299&
“Forum: Consumers Assess the Nursing Home Initiative” (Sep. 23, 1999),
http://aging.senate.gov/hearing_detail.cfm?id=272304&
“Forum: Nursing Home Residents Short-Changed by Staff Shortages” (Nov. 3, 1999),
http://aging.senate.gov/hearing_detail.cfm?id=272305&
“HCFA Regional Offices: Inconsistent, Uneven, Unfair” (Nov. 4, 1999),
http://aging.senate.gov/hearing_detail.cfm?id=272306&
“Nursing Home Residents: Short-Changed by Staff Shortages, Part II” (July 22, 2000),
http://aging.senate.gov/hearing_detail.cfm?id=272279&
“Nursing Home Bankruptcies: What Caused Them?” (Sep. 5, 2000),
http://aging.senate.gov/hearing_detail.cfm?id=272282&
“The Nursing Home Initiative: A Two-Year Progress Report” (Sep. 28, 2000),
http://aging.senate.gov/hearing_detail.cfm?id=272287&
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CONGRESS, 2001-PRESENT
 Considerably less Congressional involvement
• Senate Finance Committee hearing: “Nursing Home Quality
Revisited: The Good, the Bad, and the Ugly” (July 2003),
http://finance.senate.gov/sitepages/hearing071703.htm
 Hearings about private equity firms (Nov. 15, 2007)
• “Trends in Ownership and Quality,” House Ways and Means
•
Committee,
http://waysandmeans.house.gov/hearings.asp?formmode=detail&h
earing=601
“Nursing Home Transparency and Improvement,” Senate Special
Committee on Aging,
http://aging.senate.gov/hearing_detail.cfm?id=300437&
 But no legislation has been enacted as a result
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NURSE STAFFING
 Nursing Home Reform Law required study
of nurse staffing
 Requirement was forgotten and ignored for
years
 Finally, study done
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NURSE STAFFING REPORT
 Appropriateness of Minimum Nurse Staffing
Ratios in Nursing Homes
• Phase I (Summer 2000)
• Phase II (Winter 2001)
• Found 97% of facilities failed to meet 1 or more staffing
requirements (1.15-1.3 hours licensed staff; 2.4-2.8 hours aide)
to prevent avoidable harm to residents
• Simulation found 91% lacked sufficient nursing staff to meet 5
key care processes required by Nursing Home Reform Law
(dressing/grooming; exercise; feeding assistance; changing wet
clothes and repositioning; toileting)
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STAFFING RECOMMENDATIONS
OF EXPERTS
 Direct care staffing standard: 4.13 hours per
resident day
 Plus administrative nurse staffing
 Plus mealtime staffing
• Charlene Harrington, et al, “Experts
Recommend Minimum Nurse Staffing
Standards for Nursing Facilities in the United
States,” The Gerontologist, Vol. 40, No. 1, 5-16
(2000).
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NURSE STAFFING REPORT
CLINTON ADMINISTRATION
 Clinton (Sep. 16, 2000 Radio Address)
called for
• one billion dollar grant program to boost
•
•
staffing levels, improve recruitment and
retention, and train caregivers
establishing minimum staffing requirements
within 2 years
using civil money penalties to improve staffing
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NURSE STAFFING REPORT
BUSH ADMINISTRATION
 Bush Administration said evidence in Phase
II report was insufficient to support change
in law or regulation
 Staffing initiatives
• Feeding assistants (staff with 8 hours of
•
training to feed residents)
Nursing facilities to post staffing information,
by shift
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INCREASED REIMBURSEMENT
FOR STAFFING
 Medicare and Medicaid reimbursement
increased from $24.8 billion in 1990 to
$51.0 billion in 1998
• Congress increased rates (by 16.6%) for nurse
staffing component of Medicare rate in 2000
(component includes social services, nontherapy ancillary services, as well as nurse
staffing)
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BUT LITTLE CHANGE IN
STAFFING LEVELS
 1991-1998: staffing levels remained largely unchanged
 2000 rate increase did not increase staffing
• Government Accountability Office (GAO), Skilled Nursing
Facilities: Available Data Show Average Nursing Staff Time
Changed Little after Medicare Payment Increase, GAO-03-176
(Nov. 2002), http://www.gao.gov/new.items/d03176.pdf, found
• Medicare rates were increased 4-12% (on top of prior increases)
• Staffing remained virtually stagnant (1.9 minutes increase in nurse
staffing, but less RN, more LPN and aide time)
• Staffing increased (15-27 minutes per resident) in 4 states that
explicitly required staff increases
• GAO concluded, “increasing the Medicare payment rate was not
effective in raising nurse staffing” (page 4)
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ASSURING HIGH QUALITY
 Approaches:
•
•
•
“Mandatory and external
• “Strengthen the regulatory process
• “Improve information systems for quality monitoring
• “Strengthen the caregiving workforce
“Voluntary and external
• “Providing consumers with more information
• “Strengthening consumer advocacy
• “Increasing Medicare and Medicaid reimbursement
“Voluntary and internal
• “Developing and implementing practice guidelines
• “Changing the culture of nursing facilities”
Joshua Weiner, “An Assessment of Strategies for Improving Quality of Care in
Nursing Homes,” The Gerontologist, Vol. 43, Special Issue II (2003)
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MARKET VS. REGULATION
 For this presentation, focus on market vs.
regulation
 An enduring controversy
• Reagan Administration: deregulation (although
•
•
Nursing Home Reform Law was enacted)
Clinton Administration: regulation
Bush Administration: market-based approaches
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2001-PRESENT
 Nursing Home Initiative (Nov. 2001)
• Public reporting of performance measures
• Technical assistance to facilities through
Quality Improvement Organizations
 Revisions to State Operations Manual
(surveyor guidance)
 Quality-based purchasing demonstration
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NURSING HOME INDUSTRY
 For this presentation, industry = trade
association leadership, not workers
 Industry consistently promotes marketbased approach to regulation; quality
improvement; technical assistance; outcome
measures; customer satisfaction
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NURSING HOME INDUSTRY
 American Health Care Association (AHCA)
(trade association of primarily for-profit
facilities)
• 2000 Issue Brief called for collaborative
•
system, spending civil fine money to improve
care for residents, preventing the labeling of
chains, etc.)
Similar position each year
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NURSING HOME INDUSTRY
 American Association of Homes and
Services for the Aging (AAHSA) (trade
association of not-for-profit facilities)
• Broken and Beyond Repair: Recommendations
to Reform the Survey and Certification System
(June 2008), http://aahsa.org
• Calls for “a new oversight model”
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NURSING HOME INDUSTRY
 Voluntary initiatives
• Quest for Quality (1982)
• Quality First (announced July 2002),
•
http://www.qualityfirstnursinghomes.com/
Advancing Excellence (Sep. 2006-present),
http://nhqualitycampaign.org/
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QUALITY FIRST
 Announced July 16, 2002 by 3 national
nursing home trade associations (AAHSA;
AHCA; Alliance for Quality Nursing Home
Care [chain nursing homes]
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QUALITY FIRST
 Covenant to commit to 7 core principles
• Continuous quality assurance and quality improvement
• Public disclosure and accountability
• Patient/resident and family rights
• Workforce excellence
• Public input and community involvement
• Ethical practices
• Financial stewardship
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QUALITY FIRST
 Expected outcomes by 2006:
•
•
•
•
•
•
Continued improvement in compliance with federal
regulations
Demonstrable progress in promoting financial integrity
Demonstrable progress in clinical outcomes
Measurement improvements in CMS quality
improvement measures
High satisfaction on consumer satisfaction surveys
Demonstrable improvement in employee retention and
turnover rates
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QUALITY FIRST
 Established and paid for National
Commission for Quality Long-Term Care,
http://www.qualitylongtermcarecommission
.org/
• Co-chaired by former Republican Speaker of
•
the House of Representatives Newt Gingrich
and former Nebraska Senator Bob Kerrey
Hosted several meetings; issued several reports
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ADVANCING EXCELLENCE IN
AMERICA’S NURSING HOMES
 Voluntary campaign
 8 “measurable goals”
• Reducing high risk pressure ulcers
• Reducing use of daily physical restraints
• Improving pain management for long-stay residents
• Improving pain management for short-stay residents
• Establishing individual facility targets for improvement
• Assessing resident and family satisfaction with quality
•
•
of care
Increasing staff retention
Improving consistent assignment of nursing home staff
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ADVANCING EXCELLENCE
 Center for Medicare Advocacy, “The
‘New” Nursing Home Quality Campaign:
déjà vu All Over Again” (Sep. 21, 2006),
http://medicareadvocacy.org/SNF_QualityC
ampaign.htm
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NURSING HOME INDUSTRY
 Claims to represent residents, equating dollars
spent on care with care of residents
•
AHCA, “American Health Care Association Kicks Off
Quality-Focused Ad Campaign; Inside-the-Beltway
Ads Highlight Improved Quality of Care for America’s
Seniors and Disabled” (Sep. 12, 2008),
http://www.ahcancal.org/News/news_releases/Pages/12
Sep2008.aspx
 Same initiatives, repackaged
•
Now industry claims that helping the industry helps the
economy, financial stimulus
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AN ENDURING ISSUE




Reagan Administration: de-regulation
Clinton Administration: regulation
Bush Administration: market
Obama Administration:
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NOW
 Nursing home industry proposing to Capitol
Hill staff
• Less than annual surveys for “top tier” (which
•
it does not define)
Back to 1982
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NOW
 The financial collapse was caused, in part,
by the absence of regulatory oversight of
financial institutions. I hope the United
States does not make the same mistake by
continuing the de-regulation of the nursing
home industry. It’s time for re-regulation.
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CENTER FOR MEDICARE ADVOCACY, INC.
Toby S. Edelman
Center for Medicare Advocacy
1025 Connecticut Avenue, N.W.
Suite 709
Washington, DC 20036
(202) 293-5760, extension 104
(202) 293-5764 (fax)
[email protected]
_________________
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