HEALTH CARE/Joan Retsinas

Testing in a Post-Lake Wobegon World: Nursing Homes

Remember Lake Wobegon, where all children scored “above average.” In education, we’ve journeyed beyond there to an Eden where nobody is below average. We’ve simply rejected testing. Those standardized tests are too hard. Too unfair. Too socially and/or racially and/or ethnically skewed. Every question (is an oboe a musical instrument? Why is Christopher Columbus famous?) invites critiques. Besides, every child is unique. No test can capture that ineffable uniqueness. So parents, particularly middle-class ones, have resolutely said “no” to the battery of standardized tests that purport to show children’s progress vis à vis their counterparts, both in this country and worldwide, and those children’s progress over time.

As for evaluating teachers on the basis of children’s scores, the teachers’ unions have proclaimed myriad objections. Teaching encompasses more of those ineffable qualities that tests can never measure. So at a time when we bemoan the poor reading and mathematical skills of high school graduates, we back off from standardized tests. Or we allow the merits of testing, but decry whatever test is put forth: it doesn’t measure what we truly want to measure. Not surprisingly, as parents and teachers opt out of the tests, the tests grow useless as a benchmark to assess curricula, schools, districts.

So the federal government deserves our praise in the nursing home arena. Let us cheer their resolve to grade nursing homes. Since Uncle Sam, through Medicaid or Medicare, purchases the bulk of nursing home services, Uncle Sam is entitled to want some return for the dollar. And, since 1998, the federal government has publicized ratings on a Nursing Home Compare web-site. But from the start, those ratings anchored us in a Lake Wobegon world, where almost all homes scored above average, where only a slim percentage failed, and where homes self-reported much of the data. With a five-star rating system, the bulk of homes scored 4 or 5.

This new permutation of Nursing Home Compare ( ratchets up the testing. The government evaluated 15,000 nursing homes, rating them on government inspections, quality measures, staffing, and an overall score. You can judge your area’s homes by this report card.

Many homes now score lower than in the previous permutation. Almost two-thirds of the homes went down on “quality measures;” 13%, on “staffing.” No surprise: this test is more rigorous. Nursing homes still report their staffing levels – a key measure of a facility’s operations. But these reports are now verified by payroll data. The results of government on-site inspections show up. The report continues to monitor bed-sores, an indicator that patients may have been left in bed too long.

Crucially, in this permutation of Nursing Home Compare, Uncle Sam raised the bar on performance. One failing of nursing homes in the bleak past has been the zeal to over-medicate. Some patients need anti-psychotic medications, but some staff, particularly staff who oversee too many patients, need manageable patients. How better to manage those patients than with drugs? The government inspectors used to want to see a 15% reduction in use of anti-psychotic drugs; now it wants to see a 30% reduction. One goal of testing is to nudge the test-takers toward improvement: we are supposed to raise the bar, as facilities meet the standards. Until we reach that truly halcyon era when all homes are performing perfectly, all homes can improve.

Predictably, the industry is jarred by this new test, by the results. After all, homes that in the past scored stellar now score average, or worse. But instead of blaming a facility’s operations, the industry blames the scorecard. They level familiar-sounding objections to the report: unfair, confusing, inaccurate.

Kudos to the government for forcing the facilities that care for many of us as we age to perform better. A perfectly constructed weighted test does not exit; Uncle Sam will doubtless roll out under permutation soon. Yet without any rigorous test, we languish in Lake Wobegon.

Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email

From The Progressive Populist, April 1, 2015

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