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Distributed January 21, 2005
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About 630 Words

Vincent Mor
Protecting Our Parents: New Legislation Takes a Proactive Approach

Public policy, not market forces, should help struggling nursing homes improve. A bill introduced by Rep. Patrick Kennedy, D-R.I., leads the way by providing a variety of incentives.

Recent nursing home scandals in Rhode Island are only the latest in a long history of problems that have been repeated throughout the country. In the last six months alone, reports about poor care and outright abuse in nursing homes have surfaced in Massachusetts, Mississippi, California, Illinois, Missouri and Washington, D.C. We cannot ignore the headlines. The aging of the population, the continuing push to transform hospitals into intensive care units, and the sheer size of the aged and disabled population means that something like nursing homes will be with us for the foreseeable future – even if we invest more in home care services and alternatives like assisted living.

Nursing home scandals arise periodically because caring for other people’s mothers is hard work, poorly rewarded, heavily regulated but erratically monitored in an institutional environment where few of us would choose to spend our final months. Conflicts of fundamental values – safety vs. autonomy, homelike vs. sterile – abound, yet society requires nursing facilities to resolve them, when in our own homes we are free to make choices that reflect our own values. Resolving these conflicts means establishing a single definition of “good quality” when all of us recognize that we have many.

The difficult job of providing care in nursing homes is compounded by staffing shortages, inexperienced managers, inadequate reimbursement and competition for resources from other health care providers like hospitals, which have greater resources and garner more respect from the public.

Still, most nursing homes manage to serve their residents reasonably well. Recent research suggests that quality problems tend to be concentrated in about 15 percent of nursing homes, which tend to serve primarily poor, frequently minority, residents and have fewer staff. Those facilities engender more regulatory citations for deficient care.

Recent national policies to stimulate competition by publishing quality “report cards” of nursing homes may result in these lower-tier homes closing, leaving rural and poor urban communities with fewer long-term care options and jobs. Rather than allowing the “invisible hand” of the market to disproportionately disadvantage certain groups, we believe that government should take a more proactive role in helping these facilities improve by attracting more and better staff, facilitating quality improvement efforts and finding ways to manage the societal risk of having underperforming providers serve vulnerable people.

Rep. Patrick Kennedy, D-R.I., has introduced legislation that establishes a national agenda to improve care in these facilities, which he terms as “under-served.” The “Managing Our Medicare and Medicaid Services and Protecting our Parents Act” proposes a loan repayment program, training programs and efforts to increase family involvement in nursing homes. Professional nursing staff and administrators could have educational loans partly forgiven, much as physicians can pay back educational loans by serving in rural areas. State-sponsored training programs and special quality improvement programs would be targeted at these facilities. Finally, the bill proposes reinstituting a requirement that states must pay facilities the cost of caring for residents and requests an increased federal share of funding to meet this need. We applaud this effort to target staff incentives and improvement resources at the facilities likely to need them the most. States could reinforce this by tying future increases in payment rates to increases in staffing.

Of course, if the ownership and management of these facilities are not able to turn them around, states must be able to exercise existing regulatory authority to protect the health and safety of the residents. If need be, this could include identifying alternate operators to administer the facility and serve residents’ needs while the fate of a chronically poor facility and the residents it serves is decided. The goal here is to align federal and state financing and payment incentives so that they are in concert with federal and state regulatory and quality review functions.

Vincent Mor is chair of the Department of Community Health at Brown Medical School in Providence, R.I.

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