Trouble in the Nursing Homes

The first federal review of nursing-home performance underscores the need for improvement and also the wisdom of Congress in adopting new and stricter rules now being imposed.

There are two obvious problems: One is that the quality of care in these facilities is often unsatisfactory. The other is that the care is below standard because of the inadequacy of federal and state funding so that facilities must rely heavily on low-paid, relatively unskilled employees.

Publication of the report by the Health Care Finance Administration, which runs Medicare and Medicaid, already has drawn fire both from those who operate the nursing homes and who argue that the report is too demanding and misleading, and from the organizations seeking to protect the interests of patients, who say that the report is not harsh enough.

The criticisms miss the point. As Dr. William Roper, administrator of the Health Care Finance Administration, said on releasing the study, it is “a major step forward in presenting information that can be helpful to average persons seeking a nursing home for themselves or members of their families.” It is but a step, not a final answer. The detailed reporting of violations at individual institutions can help in making a selection, but case histories make clear that the report alone is not an adequate tool in the selection process.

The criticism of the report is similar to the complaints from hospitals when Roper began releasing mortality rates for individual institutions. One can hardly imagine the reception that will be given forthcoming reports on doctors’ performances with Medicare and Medicaid patients. There is no doubt that the reports can be improved to make them more useful to consumers. This initial effort on nursing homes makes no distinction between major and minor infractions--a failure that can be unfair to some of the facilities. But the decision to make the information routinely and regularly available to the public was the right one, providing yet another tool to improve the quality of care.

Despite findings of widespread violations of physicians’ instructions and extensive breaches of sanitation regulations by long-term care facilities, Roper was still able to say: “We are convinced that the quality of care in nursing homes is better than it has ever been.” However, he hastened to add: “But it can be yet better.”

California already has in place tougher inspection regulations for nursing homes than the federal standards. That accounts in part for a violation rate in the state higher than national averages for many of the 32 standards by which the institutions were judged in the federal study.

Last summer, when the California minium wage was raised from $3.35 to $4.25 an hour, the state granted a 6% increase for Medi-Cal patients in skilled-nursing facilities, bringing the state rate to $51.84 per patient day. About half the increase covered the cost of raising the minimum wage. The balance allowed modest increases for other staff members, but not nearly enough to cover the need for increased compensation for registered nurses. Even with those modest increases the cost of long-term care in the Medi-Cal program will rise to $1.2 billion this fiscal year, consuming about 30% of all the Medi-Cal budget for the year and financing about 65% of the nursing-home population in the state, according to the state Department of Health Services.

Obviously the level of funding is not enough to ensure one of the reforms that is most requested--the availability of more registered nurses to oversee care. Clearly some nursing homes are doing a better job than others despite the current fiscal restraints. And clearly there is no excuse for the gross violations of standards that are still reported. Better inspection will encourage better management, but high-quality care will remain elusive until the Medi-Cal funding is adequate.