Consumer Reports' September exposé of poor nursing homes has spurred a round of The Blame Game. Typically the game starts when investigators unearth abysmal facilities. Who is to blame? The ball is in the air. Evil owners? Prosecute them. Lackadaisical staff? Fire them. Weak regulations? Strengthen them. Insufficient money? Spend more. A few years after one round, another will start, sparked by another exposé.
The first round started after Medicare/Medicaid legislation (1965) steered substantial federal money toward nursing homes, giving Congress a substantial vested interest in assuring quality. (Arkansas Congressman David Pryor went undercover as an orderly in a nursing home.) Indeed, Consumer Reports' litany of horrors is outrageous: pressure sores in residents who have no risks for them; medications not given; calls for help ignored. Yet, in the early 1970s, too many homes were firetraps, owned by embezzlers. Those early investigators found patients tied to beds or drugged into lethargy. They found meager meals, omnipresent filth and no medical oversight. Read Sen. Frank Moss and Val Halamandaris's Too Old, Too Sick, Too Bad  or Old Age: The Last Segregation, by Ralph Nader's investigators . Those exposés prompted the first of a series of reform regulations.
This report, though, does more than detail the horrors. Crucially, it analyzes the conundrum: In a super-regulated industry, why are so many facilities sub-par?
The usual villain-to-blame is Medicaid. The government program pays for more than half the beds in the country. And states try to keep Medicaid reimbursement low. Presumably, facilities with higher Medicaid reimbursement, or fewer Medicaid beds, would give better care. Statisticians, though, found no strong correlation.
Another explanation -- the "few bad apples" one -- contends that most nursing homes are fine; a few outliers grab the headlines. Consumer Reports, though, found that those outliers fit a pattern. For-profit homes, particularly those owned by in-state chains, were more likely to deliver sub-par care. In a classic free-market model, those facilities, intent on wooing customers, might deliver better care than nonprofit ones. Yet residents are not customers: The person with Alzheimer's Disease cannot research better facilities; the person on a ventilator cannot pack up and leave. However awful a facility, most residents are trapped.
This report does not call strongly for more regulations (though it notes that the federal government does not specify minimum staffing per resident). Indeed, in an industry where so many staff spend so much time filling out paperwork, it would be hard to call for more regulations.
Instead, this report tosses the blame-ball to states. States regulate nursing homes, and state legislatures, swayed by facility owners and lobbyists, have given a not-so-subtle message to inspectors: Go easy. Facilities routinely challenge poor surveys, appeal citations, fight down fines. And states yield.
For instance, the federal Centers for Medicare and Medicaid Services reported a 7.6% increase in deficiencies written by state inspectors since 2003 -- but fewer deficiencies carry the codes that denote actual harm to a patient. With a low-grade deficiency, a facility submits a "plan of correction" and continues to operate.
The 1987 federal nursing home reform law let states impose fines, but states have set token amounts and fined only 50% of the homes that they could have. Of 12 five-time repeaters on the list of poor homes, eight received no fines between 1999 &endash; 2004. As for shutting down a home, the federal government closed only eight in 2005, and states rarely invoke that power.
This investigation into 16,000 homes nationwide was both exhaustive and specific. For each state, Consumer Reports cites both the high-performing and the low-performing homes. Spurred on by the lists, nursing home reform advocates, coupled with reporters, will doubtless force states to be more vigilant.
Yet for-profit nursing homes are driven by profit. However compassionate the staff, however principled the administrators, the bottom line for many homes is not patient care, but the same bottom line that drives all businesses. Consider the correlation among patient care, costs and profits. If administrators let the quality of care drop (fewer staff, less training, less equipment), costs will drop and profits rise. Residents are too frail, too vulnerable to complain, much less leave. But if administrators raise the quality of care, costs will rise and profits drop. Shareholders will complain.
Watch for another round of the Blame Game in a few more years.
Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email firstname.lastname@example.org.
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