Nursing home providers are welcoming the idea of linking federal payments to quality performance, but some consumer advocates wonder why nursing homes need to be rewarded for offering care they should already provide.
Three federal bills-two in the House and one in the Senate-that would establish payment incentives for nursing homes with better performance scores were introduced in Congress last month and are expected to be reintroduced in the next session. The bills are written vaguely and leave open for debate how much money needs to be allocated and how the quality measures are going to be defined.
"It's a good start," said Stephen Guillard, chief executive officer of nursing home operator Harborside Healthcare and chairman of the Alliance for Quality Nursing Home Care, a group of for-profit providers.
The alliance supports two of the bills-those introduced by Sen. Ron Wyden (D-Ore.) and Rep. Philip English (R-Pa.)-but it hasn't reviewed the third, which was introduced by Rep. Marcy Kaptur (D-Ohio), Guillard said. He added that it seems likely that the bills will be debated in the next session, but it's too early to tell if any will pass.
The alliance and its members say pay-for-performance initiatives will increase quality overall, and Guillard said he prefers performance measures that score facilities against patient outcomes. The CMS' Nursing Home Quality Initiative rates facilities on 15 measures-among them pressure sores, mobility and weight loss-for current residents.
The initiative was set up to improve quality, provide consumers with more information and allow greater oversight of the facilities. Nursing homes' scores on these measures are posted on the CMS' Web site, but some providers have complained they don't accurately depict the quality of a nursing home, partly because the measures aren't primarily based on outcomes.
Wyden's and English's bills would establish 10 to 15 new measures. A spokesman for the American Health Care Association, a long-term-care advocacy group, said the association is behind pay-for-performance measures and is reviewing all three bills.
All three bills would establish measures, but none provide specifics or cost estimates for the programs.
The Wyden and English bills call for a voluntary program that would decrease annual payment adjustments for underperforming nursing homes by 1% while increasing the adjustment 1% to 2% for top performers.
Wyden's bill says the plan should be budget- neutral-meaning that HHS shouldn't allocate more funds for the pay-for-performance program unless it pays for it by trimming spending elsewhere. English's bill doesn't have such a provision but does call for the establishment of a long-term-care financing commission that would study financial outlooks and trends.
Kaptur's bill calls for the HHS secretary to develop one or more payment systems for a pay-for-performance pilot project that would last no more than five years, but it leaves most details-such as what measures to use and how many nursing homes would be involved-up to the HHS secretary. If any of the bills are enacted, nursing homes would likely have to spend resources on reporting and educating staff on the new provisions, but until the final rules are determined it's difficult to say how much the programs would cost the facilities.
Cynthia Rudder, executive director of the Long Term Care Community Coalition, a not-for-profit consumer advocacy group, said she's against the idea of giving nursing homes more money to provide better care because they should be providing good care already. She also said that no matter what measures are designed, the system would be vulnerable to gaming.
One way to avoid gaming is to design a system with rotating and hidden measures, said Brant Fries, a professor at the University of Michigan's School of Public Health. Fries helped develop the congressionally mandated national resident assessment instrument, which is used to assess patient status in most nursing homes. He said some of the pay-for-performance measures could be kept consistent, while others could change over time and others could be kept secret.
The pay-for-performance idea has picked up steam, but there aren't "reams of that data" that say these types of programs work, said Arthur Levin, director of the Center for Medical Consumers, an advocacy group. "It has the shiny new toy effect," he said.
Levin said the pay-for-performance ideas could lead to the notion that the only way to improve quality is by giving providers more money, but he conceded, "Money is a great motivator."