Feds ‘no-show’ on LTC policy

The American Public Health Association (APHA) is the oldest and largest national organization devoted to research and debate on public health issues. With roughly 50,000 members, APHA is significantly smaller than either the American Medical Association or the American Nurses Association. Over the years, however, APHA often has exerted a powerful influence as a research and advocacy group because of its close association with the U.S. Public Health Service and the Department of Health and Human Services.

In the recent past, the APHA annual meeting has been a valuable source of innovative ideas on healthcare administration and financing relevant to SNFs. In 1998, for example, HCFA senior researcher Marvin A. Feuerberg, PhD, used the annual meeting as an opportunity to present his agency’s comprehensive report to Congress on the effectiveness of the SNF survey and certification system and the use of incentives for quality improvement. In 1999, the APHA annual meeting keynote speaker was Sen. Bill Bradley (D-N.J.), who used the occasion to outline a proposal to replace Medicaid financing of long-term care with a dedicated public funding source. The sessions of the APHA Gerontological Health Section have been particularly important as a bellwether of research and policy discussions on nursing homes and long-term care.

Since 2000, however, topics related to nursing home administration and financing have become less prominent at APHA’s annual meeting. The most recent sessions, held in Boston last November, included hardly any discussion of public policy for residential long-term care. Most SNF-related presentations were limited to “poster sessions” in which academic researchers were required to reduce their studies to a handful of large poster displays. Research panels that explored alternative public policy approaches to long-term care described practices in Japan, the Netherlands, and the United Kingdom. There was far less discussion of innovative policy practices in the United States

Why the drop-off? One important reason has been the absence of participant researchers from the federal government. It’s almost impossible to seriously debate public policy options without the participation of experts from the public sector. That expertise, however, has been noticeably absent from APHA throughout the Bush II administration. Officials from the Centers for Medicare & Medicaid Services (CMS) and other federal agencies have been much less visible in the scientific sessions of APHA’s Geronotological Health Section during the past five years than they were during the 1990s.

Unstable government finances and reorganization provide part of the explanation. When federal appropriation bills are not passed on schedule, agencies are severely limited in authorizing travel for their employees. Federal researchers and officials who have low expectation of being reimbursed for their expenses are not likely to reach in their own pockets for the roughly $1,000 needed to attend the conference.

Another barrier may be discomfort among administration officials over what their research staff might say. Dr. Feuerberg, for example, criticized CMS officials for “watering down” the executive summary of the agency’s 2002 study on the relationship between nursing staff levels and quality of care. Understandably (if regrettably), administration officials whose own research staff may cast doubt on the wisdom of agency policies may prefer to keep their findings under wraps.

With federal LTC policy researchers absent, the 2006 APHA LTC sessions were dominated by relatively inexpensive studies conducted by individual academics.

These studies fell generally into two groups: research on factors influencing SNF quality of care and research on the impact of financing policies on the cost of care. Of these, the studies on quality were probably of greater interest to nursing homes because they contributed to growing skepticism about the ability of government-designated “outcome measures” to support continuing quality improvement.

Christopher M. Kelly, PhD, and Lloyd J. Edwards, PhD, of the faculty of the University of North Carolina provided potentially the most important analysis of the quality issue at a poster session innocuously described as “Innovations in Long-Term Care.” They noted a measurable decline across the board during the past six years in severe nursing home deficiencies—those involving actual or potential death or injury to patients, as opposed to paperwork irregularities. However, a review of state nursing home inspection data from the CMS OSCAR (Online Survey, Certification, and Reporting) database found significant inconsistencies in quality improvement among the 50 states. Their findings indicated that higher ratios of registered nurses to nursing home residents led to lower overall deficiency rates, while greater overall nursing staffing (registered nurses, licensed vocational nurses, and certified nursing assistants) was associated with lower rates of severe citations in particular. Moreover, states that maintained higher standards for nursing home administrators in terms of education, examination, and certification were more likely to experience fewer severe deficiencies. In short, confounding policymakers who argue that widespread adoption of outcome measures and “evidence-based best practices” is the key to higher-quality SNF care, the study by Kelly and Edwards underscores that quality improvement comes at the price of higher nursing staff levels and more highly qualified administrators.

Monika Lopez-Anuarbe and Dennis R. Heffley, economists at the University of Connecticut, presented another intriguing study with potential policy implications. Their ongoing work focuses on the suggestion that policies designed to discourage the transfer of assets from older Americans to younger family members for the purpose of establishing Medicaid eligibility are ineffectual and potentially misguided. Lopez-Anuarbe and Heffley noted that earlier research found that the mean asset transfer among new Medicaid recipients living in nursing homes is less than $4,200—hardly the image of upper middle-class retirees “gaming” the Medicaid system and triggering punitive regulations. The economists also reported preliminary research documenting that most elderly who transfer assets do not qualify for Medicaid and do not intend to file for Medicaid. They suggest, as a result, that state-specific Medicaid policies aimed at asset transfer have minimal impact on costs.

These types of research results are intriguing, but their impact is inconclusive. In the past, they might have led to a serious discussion at APHA and in Washington about the merits of current policies. In today’s policy climate, however, they receive little attention and less debate. Apparently, the federal government favors research-based practices for long-term care, but it has little interest in the results of serious research applied to its own long-term care policies.

To send your comments to the author and editors, e-mail stoil0107@nursinghomesmagazine.com.


Requests for the APHA presentation on “Nursing Home Quality: The Effects of Ownership, Staffing, and Administration on Regulatory Outcomes” should be addressed to Christopher M. Kelly, Institute on Aging, UNC, 720 Martin Luther King, Jr., Blvd., Chapel Hill, NC 27599. Requests for the presentation on “Asset Divestment and Spend-Down in the Market for Nursing Home Care” should be sent to Monika Lopez-Anuarbe at monikauconn@yahoo.com.

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