May 29, 2016

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 As governor of Ohio, he created this pro-business group which reviewed 2476 rules and rescinded or amended 1398.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.

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