A top panel from the National Academies of Sciences, Engineering and Medicine has released a scathing report on the state of nursing homes in the United States. Operators, owners, regulators and payers are all defaulting patients and residents, according to the report.
“The way the United States funds, delivers, and regulates nursing home care is inefficient, inefficient, fragmented, and unsustainable…. Immediate action to initiate fundamental change is needed,” according to the 605-page study.
A few reforms, a few studies
The report suggests some specific reforms, particularly in the areas of staff compensation and training, ownership oversight and transparency. Yet in many cases this requires further study and research into more fundamental reforms, including the development of new models of care and financing.
The report was the first time the National Academies had comprehensively examined nursing homes since 1986. The report identified significant issues, including “neglect and abuse of residents, poor quality of life, excessive costs, oversight inconsistent (or absent), and the need for high-quality outcome data.
Thirty-six years later, the new report concluded: “Despite significant steps to improve the quality of nursing home care in [1987 legislation]the current system often fails to deliver high quality care and underestimates and under-prepares care home staff for their core responsibilities.
a long way to go
In less polite terms: Although there have been some improvements in the quality of care, nursing care facilities still have a long way to go if they want to provide their patients and residents with the care they deserve.
Among the report’s most important recommendations is a call to designate a specific percentage of Medicare and Medicaid payments for direct care services. Since these federal payments account for nearly all of nursing home revenue, such a move would likely increase social worker compensation.
By limiting revenues that could be allocated to other expenses, including returns to investors, this targeting would make facilities less attractive to for-profit operators and owners. Whether nonprofits could fill the void is an open and important question.
The report also recommended several changes to nursing home staffing. It included 24/7 registered nurse coverage, a full-time social worker and an infection control and prevention specialist.
A challenge: The report also called for new incentives for small homes. But a full-time nurse, infection control professional, and social worker may not be cost-effective for a small home with only, say, 10 residents.
The group also called for a fresh look at minimum staffing requirements. Current federal guidelines are decades old and have never been enforced. In this case, an in-depth study of staffing needs in 2022 would be valuable.
Funding for long-term care
On funding, the panel hinted at significant changes without making specific recommendations.
For example, he urged using “detailed and adequate financial information about nursing homes” to determine whether state Medicaid payments for long-term residents are sufficient to fund high-quality care. This is a crucial first step, but it would still leave states a lot of leeway in how much they pay for the right to long-term care.
The study also recommended “moving toward a federal long-term care benefit by studying how to design such a benefit” and creating demonstrations of state public insurance.
I’m glad the committee recognized the potential need for public long-term care, but this issue has been well considered. There is an absence of political will to act, not a lack of data.
And while state protests can be useful for many benefit reforms, a social insurance program is more effective at the federal level than state-by-state. Washington State’s experience is a good example of the problems of a one-state solution.
Few of the recommendations in this report are new. Many, in fact, have recently been suggested by the Biden administration. And most have been debated for years. Few will read the National Academy’s 600+ page report. But perhaps it will encourage regulators and lawmakers to finally act before nursing homes turn into an epic market failure.