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Statistics don't lie, but…

December 1, 2007
by Long-Term Care Editors
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Statisticians—that's another story. And when politicians use statistics to achieve their particular policy goals—well, watch out!

That observation wouldn't surprise many students of the Washington scene. Let's face it; statistics are simply one of the many tools used by policy practitioners to document not only the need for policy change, but the policy change desired. And when the policy topic is as volatile as nursing home quality, statistics fly fast and furious.

I write this just one day after the conclusion of the first wave of congressional hearings on the involvement (and repercussions) of private equity's foray into nursing homes. But the issue, in my mind, is not the pros or cons of investor-owned nursing homes (not that I don't have opinions in that regard. See my article in Nursing Homes/Long Term Care Management, “When It Comes to Quality, Wall Street Might Be a Problem,” May 2005, p. 18.) Rather, it is the use of data to support policy goals that really gets my goat. Here's just one example:

At the November hearings before the Health Subcommittee of Ways and Means, the Service Employees International Union (SEIU) witness compared the number of nursing home survey deficiencies from the annual inspection prior to being bought by private equity against the number of deficiencies found during the most recent annual inspection. The results, he argued, were “distressing.” SEIU found a 29.4% increase in violations of federal resident care standards during the most recent inspections of Mariner facilities after their being acquired by National Senior Care—more than double the 11.9% increase in violations in the other homes in the states in which Mariner operated. Ergo, keep private equity out of the nursing home business.

The above-cited hearings are only the most recent reflection of data selection supporting policy biases. Certainly, as far back as the summer of 1998, increasing attention has been paid to the quality (or lack of it) in America's nursing facilities. Beginning with hearings held in July of that year (by the profession's long-standing nemesis, the Senate Committee on Aging), nursing homes have occupied a central position in the healthcare policy arena. Those events were the initial salvos in what I have referred to previously as a decade-long national “crusade against nursing facilities.” To listen to Senator Charles Grassley (R-Iowa), then chair of the Senate committee, and Nancy-Ann Min DeParle, then administrator of the Health Care Financing Administration (now CMS), nursing home performance was on a downward slope in 1999, with the survey process legislated by OBRA seeming only to document, not reverse, that trend—based, of course, on survey results.

Here are some of the details reflecting HCFA survey data showing differences between 1998 and 1999—and supporting, obviously, the need for more rigorous federal oversight:

  • “Poor quality of care” continued to increase, as cited in 21% of facilities surveyed.

  • Citations for pressure sores increased from 17.1% to 18% of facilities reviewed.

  • “Failure to preserve dignity” rose from ninth place in frequency to sixth.

  • Inadequate or inaccurate care plans increased in frequency from 15.2% to 16.1% of homes surveyed.

But, wait just a minute. Shortly thereafter (in 2001), the Institute of Medicine (IoM) unveiled its own report on the quality of care in the nation's long-term care facilities. The Institute set up a committee to assess long-term care services in the United States, including nursing homes, assisted living facilities, and home health services. This was the first report on long-term care the IoM had issued since its 1986 landmark study that spurred creation of the federal nursing facility survey and certification system. In its 2001 report, “Improving the Quality of Long Term Care,” the IoM concluded that the quality of care provided by nursing facilities had actually improved over the decade since OBRA, even though nursing homes were then serving a more seriously ill population.

The IoM review focused on outcomes in such areas as restraint use, the prevalence of pressure sores, malnutrition, continence care, and pain management. In the area of physical restraints, for example, the report pointed to a 41% decline in their use from the early 1990s. While improvement in other areas of care was not as pronounced, the report certainly didn't paint the bleak picture presented by CMS. So, what's going on here?

Well, what's going on is an example of the self-fulfilling prophecy. CMS, of course, assumes that the survey system actually measures quality of care. As part of the campaign initiated as far back as 1998, it emphasized more rigorous surveys, especially in states with traditionally lower levels of citations. The result was, of course, higher levels of citations. CMS's conclusion: Those higher levels of deficiencies were conclusive proof that quality had declined.

And it gets worse. Actually, policy-makers castigate the system when it suits their purpose—and use it when it supports their underlying policy goals. Sen. Grassley, in a letter just a couple of years ago to the administrator of the CMS: “…it is apparent from our review that the survey and certification process upon which we rely for accurate, objective and independent data on the operation and activities of facilities, is just plain broke. It has been corrupted by unscrupulous individuals and we need to restore the integrity of the system in every state and locale.” Yet, it is that same “corrupted” system that the senator (like SEIU) relies on for supporting data when arguing in a recent letter (October 2, 2007) to the comptroller general against the ownership of nursing homes by private equity companies.