Why nursing homes won't be deemed - accredited by a private group

Nursing Homes, Sept, 1998 by Beth A. Klitch

The Health Care Financing Administration (HCFA) has finally released its long-awaited report to Congress on private accreditation (deeming) of nursing homes, regulatory and nonregulatory quality improvement incentives and the effectiveness of the survey and certification system. In November 1996, HCFA contracted with Abt Associates for an independent evaluation of these congressionally mandated topics. Abt Associates has performed other studies for HCFA, including a significant study on the quality of life of nursing home residents.

The first question that Abt Associates addressed in the current study was, "Should nursing homes be offered a choice between the traditional state survey process and private accreditation to demonstrate compliance with Medicare's nursing home requirements?" The report notes that proponents of deeming believe that:

* the current survey and certification process is punitive and inflexible, with inconsistent implementation and enforcement.

* most nursing homes strive to provide good quality care and succeed.

* the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), an organization that accredits a variety of providers including nursing homes, is more efficient than HCFA because it relies primarily on facility administrators and clinical staff to enforce standards and on industry expertise to set and revise standards.

* if some nursing homes choose accreditation to demonstrate compliance, states can then focus their resources on substandard nursing homes.

According to the HCFA report, opponents of private accreditation argue that:

* for the most part, nursing homes are not managed by "professionals."

* the average facility has a high level of compliance problems. There is a need for direct government monitoring and enforcement.

* accreditation does not "work" in other contexts, even hospitals.

* there is an inherent conflict of interest involved because facilities pay the accrediting organization for the survey.

* accrediting bodies are not accountable to the public or to government.

The study notes that Congress elected to give HCFA broad discretion in deciding whether to allow deemed status for nursing homes, unlike other healthcare facilities for which HCFA must grant deemed status if the private accreditation organization's program demonstrates compliance with Medicare conditions of participation or other requirements.

The report concludes that for deeming of nursing homes:

* JCAHO would have to revise several standards to provide reasonable assurance that Medicare requirements would be met.

* JCAHO standards are weighted heavily toward structure and process measures, while HCFA standards are more resident-centered and outcome-oriented.

* In contrast to HCFA surveys, observed JCAHO surveys did not collect sufficient information to assure compliance with Medicare requirements. Generally, observations of resident care were not a priority.

* HCFA's survey system is more stringent in defining steps to be taken to correct deficiencies.

* JCAHO surveyors seem to miss serious deficiencies that HCFA surveyors identify.

* Public access to JCAHO survey findings is severely limited.

Although previous studies have quantified the cost savings to Medicare of allowing deeming for nursing homes to be $2 million to $37 million annually, depending upon how many facilities participate, the report concludes that "the potential cost savings of deeming would not appear to justify the risk to the health and safety of the vulnerable nursing home population."

This conclusion appears to rule out any likelihood of deeming in the near future, but the HCFA report does leave open several doors. The report states that:

The problems identified with the JCAHO survey do not necessarily apply to other potential accrediting organizations. Fragmentary evidence from the new "Longterm-care Evaluation and Accreditation Program" (LEAP), a competitor of JCAHO that began accrediting nursing homes in November 1997, suggests that their survey may be very different from JCAHO's. If future empirical studies produce convincing evidence that LEAP, other accrediting organizations, or a revised JCAHO survey meets all the criteria for comparability with the HCFA survey discussed in this report, then it might be time to revisit the issue of deeming.

In the second section of the report, Abt Associates reviewed research linking payment to improved outcomes and other nonregulatory quality improvement initiatives. The report notes that the concept of using monetary incentives to improve the quality of care and to promote quality of life for nursing home residents has been discussed for many years. HCFA found there were no currently operating Medicaid incentive systems, although several states had employed them in the past. Even past incentive systems' experiences could not be easily analogized to current regulatory and industry conditions. The report concludes that there are no incentive systems that could be pulled "off the shelf" and quickly implemented. Therefore, "there is a general recognition that additional research/demonstration projects conducted under current conditions would be necessary before incentive payment could be considered as a viable option."