Sense, Common Sense, and Nonsense

Massachusetts has a problem with nursing home quality. A recent report by the Boston Globe found that a number of the state’s for-profit nursing homes provide substandard care—and pay their chief executives million dollar salaries. Earlier investigative journalism revealed that in several facilities, the trouble started when an out-of-state private equity firm bought the nursing homes. Previously high performing homes suddenly were cited for a variety of deficiencies, such as lax infection control and a rise in pressure ulcers (bed sores), which seemed to be directly linked to a corporate decision to cut the nursing staff. Then came a couple of disturbing deaths of residents, such as the case of an aide who accidentally dropped a resident, resulting in her death a few days later. The state Department of Public Health investigated. Fines were levied. And now the Massachusetts legislature is considering tougher laws to deal with the situation: higher fines, more draconian penalties for unsafe conditions in area nursing homes. Who could disagree with a strategy to promote basic health and safety standards in nursing homes—a standard we thought we had achieved after exposes in the 1980s led to sweeping federal regulation of nursing facilities (OBRA-87, the so-called “Nursing Home Reform Act”)? The goal is indisputable; the strategy is questionable.

The proposed legislative changes are billed as “common sense regulations.” Everyone seems to talk about common sense regulations these days, except the most extreme politicians such as Ted Cruz who want to get rid of all regulations. Republican presidential hopeful John Kasich touted as a model that he would emulate at the federal level the “Common Sense Initiative Office.” As governor of Ohio, he created this pro-business group which reviewed 2476 rules and rescinded or amended 1398. President Obama talks about common sense gun safety reform. Massachusetts governor Charlie Baker has recommended reforming the disaster-ridden Department of Children and Families by imposing common sense regulations. The list goes on and on. But the problem is that our intuitions about how the world works, our common sense solutions to how to make it better, are often mistaken.

If modern science has shown us one profound truth, it’s that behavior, whether of man or of molecules, is often entirely unexpected. Common sense told us that some illnesses were divine punishment for immoral behavior—after all, poor people living in crowded urban areas were more prone to various outbreaks than wealthier people living in sparsely populated rural areas. Common sense told us that some diseases were due to particulate matter, to something floating around in the “miasma,” and surely not to invisible, live microorganisms. Common sense told us that time has nothing to do with the speed at which you travel. Common sense told us that light is either a particle or a wave but not both. Common sense was plain wrong.

Health policy is similarly full of surprises. In the policy arena, we talk about “unintended consequences” of our actions. Now the fact that things don’t always turn out the way we planned doesn’t mean we shouldn’t plan. In the case of nursing homes, it doesn’t mean we shouldn’t have any regulations. But it does mean we need to evaluate whether our interventions have the desired effect. And in the case of substandard nursing homes, I strongly suspect, based on studies documenting the relationship between staffing ratios and quality of care, that better surveillance and tougher penalties are only a small part of the solution. What we really need is more staff and better paid staff. And that means higher levels of Medicaid reimbursement to nursing homes (the majority of long-stay residents are on Medicaid), which means that the states have to increase what they pay nursing homes.

Between 2009 and 2012, 40 states froze or cut Medicaid reimbursement to nursing homes, though these trends are gradually reversing. Massachusetts is considering, as part of the 2016-2017 budget, increasing its payments to nursing homes. How this provision will fare in the final budget remains unclear. It’s easier to use the stick than the carrot. But only careful study of whatever policies are instituted will reveal whether they’re working. So far, the evidence favors more and better staff as the best way to improve nursing home quality.

You Get What You Pay For—Or Do You?

The Affordable Care Act, as it turns out, isn’t just about providing health insurance coverage for the 40 million previously uninsured Americans. It’s also about reforming Medicare, in part to pay for some of the costs of providing health insurance for everyone, in part to keep Medicare from going bust, and in part to improve the quality of care provided by Medicare. The favorite strategy for modifying Medicare is “value-based purchasing,” which is another name for pay-for-performance. The idea is simple: don’t just pay whatever doctors or hospitals ask for and don’t pay per service (the original fee-for-service model); instead, pay based on results. After all, physicians aren’t supposed to perform tests and procedures just for the sake of doing something; they are supposed to do things in order to improve health. So why not pay physicians only if they make people better? 

The problem, of course, is that not everyone will get better, no matter how state of the art their treatment, and some of them will get better but along the way they will also suffer from all kinds of complications. To deal with the realities of taking care of people who are old and sick, Medicare has adopted a policy that rewards—or penalizes—hospitals based on their performance on a combination of measures: the processes of care, the outcomes of care (specifically 30-day mortality), the patient’s satisfaction, and whether or not patients are readmitted to the hospital within a month of discharge. The big question is, does this approach work?

Previous studies have failed to show any benefit on clinical processes or patient satisfaction. Now, a new study in BMJ suggests that it doesn’t improve mortality either. The authors examined mortality among patients with heart attacks, heart failure, or pneumonia (the 3 conditions for which Medicare “incentivizes” hospitals using its value-based reimbursement scheme). They compared mortality rates for these conditions before and after the introduction of Hospital Value-Based Purchasing. They studied whether changes in mortality in the target conditions differed from changes in a comparable group of patients with other medical conditions. They tested whether the trends were any different at hospitals that didn’t participate in the HVBP system. And to look for trends, they determined mortality rates over a 3-year period before the introduction of Hospital Value-Based Purchasing and over the 3 years after its introduction. The result: nothing changed. 

Not everyone will be satisfied with the authors' choice of the comparison group—either of patients with different medical conditions or of hospitals that participated in a different reimbursement scheme. The risk adjustment process might be flawed. Maybe 3 years wasn’t long enough to see an effect, especially since the incentives have been changing—initially, hospitals were rewarded if they did well, now they are penalized if they do poorly, and the magnitude of the penalty increases annually. So it would be premature to conclude that value-based purchasing is a failure. But surely it isn’t a great success, either, if no one has been able to prove that it does what it’s supposed to.

Medicare has the potential to shape geriatric care in the U.S. There’s no question that strategies invoked in the past such as the introduction of prospective payment for hospital care (ie paying a fixed amount for a given condition, rather than a fixed amount per day in the hospital) have made a huge difference in both costs and outcomes. But it’s not at all clear that the prevailing enthusiasm for pay-for-performance is the answer to providing better, more cost-effective care to older people. 

Maybe we need to go back to the drawing board and analyze the weaknesses of our current system. Perhaps what we will find is that the weaknesses are not just fragmentation, lack of coordination, and the triumph of high tech over high touch, although these are all important. Perhaps what we will find is that the weaknesses include a focus on disease rather than function, on individuals rather than families, and on the values of physicians rather than patients.

Beyond Doctoring

I’ve long been amazed by the legerdemain that went into deciding what Medicare will cover and what it won’t. I’m not talking about decisions made in the past decade about what procedures to pay for, by and large rational decisions that have been based on a careful analysis of the evidence supporting their efficacy. I’m talking about some of the most basic aspects of Medicare, such as its exclusion of long term care. Now I recognize that the main concern of those who crafted the 1965 legislation was to provide some kind of health insurance for older people without busting the budget. To achieve this end, they decided to distinguish between things that are medical (which Medicare would ostensibly cover) and things that are not (which it wouldn’t). What that distinction has meant is that housing, transportation, diet, and all kinds of other nominally social goods are off limits for Medicare coverage. A new study by Elizabeth Bradley and her colleagues at Yale shows just how arbitrary—and often counterproductive—such a conceptual divide actually is.

Following up on their groundbreaking work in which they showed that countries with higher social service spending relative to health care spending had better health outcomes, the study team compared the performance of the 50 states (and the District of Columbia) over a 10-year period, from 2000-2009. They defined the extent of each state’s investment in social services by calculating the ratio of social service plus public health spending (on education, income support, nutritional assistance, housing, transportation, and the environment) to the state’s total government health care spending (Medicare plus Medicaid). Then they examined the relationship between this ratio and eight health outcomes (including the percent of the population that is obese, has asthma, or has functional limitations, and mortality rates for heart attack, lung cancer, and diabetes). What they found is that states with higher ratios of social to health spending had significantly better health outcomes (in 7 of the 8 domains).

It's striking that the variability in spending on health care (as a percentage of GDP) across the states is considerable, ranging from less than 4 percent in Colorado, Utah, and Wyoming to nearly 10 percent in Maine, West Virginia, and Missouri. Likewise, the variability in spending on social services and public health is dramatic, going from about 12 percent to over 20 percent. The net effect is that the allocation of resources between social services and health care differs substantially from one part of the country to the next.

It’s a complicated study and I’m sure that methodology mavens will have a field day with it. But the attempt to assess the contribution of social supports to outcomes is so reasonable and the results are so striking that we have to take very seriously the idea that social factors are a major determinant of health and well-being. I’m convinced this is particularly true in older people, whose quality of life is at least as affected by where they live and their ability to find meaning in life as it is by their physical ailments. I suspect that this study is as important as work by Michael Marmot showing that health worsens as people descend the social ladder—not just because of income inequality, but also because of discrepancies in social status. If we want to foster good health, which the World Health Organization defines as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity,” we need to focus on relationships and housing as well as on drugs and devices. And for older people, that may mean user-friendly computers and better assisted living facilities rather than a left ventricular assist device or a new monoclonal antibody.