Six of the measures address the short-stay patient population, including one of three targeting satisfaction. That distinction plays a major role in some of the objections to the NQF measures.
The AHCA’s Fitzler argues that the measures should be closer to being equally weighted between long-stay and short-stay residents, because of the large numbers of short-stay residents that nursing homes care for as a result of their turnover.
“We really don’t think there were enough measures approved for the short-stay population,” Fitzler said at an NQF meeting addressing appeals of the measures. “We’re looking for an equal number of measures for the short stay.”
In its written appeal, the AHCA questions the usefulness of the short-stay measures as being representative of a Medicare nursing home patient, and argues that they “fall short in measuring quality with the growing short-stay population.” An NQF committee meeting April 11 addressed the appeals, noting that the majority of nursing home patients at a given time are long-stay.
Currently, most of the spending on nursing home care is covered by Medicaid, but resident out-of-pocket and Medicare spending are sizable as well, according to the Medicaid and CHIP Payment and Access Commission. Of the $137 billion spent on nursing home care in 2009, Medicaid spent $45 billion and Medicare paid $28 billion (See chart).
The AHCA says the new measures’ emphasis on long-stay residents may lead to lower overall quality scores that result from Medicaid’s generally lower reimbursement rates than Medicare.
“If Medicare funding leads to better quality and yet there is an inadequate number of Medicare program quality measures, are nursing facility quality and policy decisions unintentionally being negatively biased by the predominance of the long-stay (underfunded Medicaid population) measures?” Fitzler writes in the AHCA’s appeal.
But one of the heads of the steering committee that oversaw the revision of the nursing home measures points out a nuance to the measures that might make a difference to those objections. The measures do not depend on who the payer is but to how long a patient is in the nursing home. So, long-stay residents who start out as short-stay residents will show up in the short-stay patient measures during their first 100 days of stay in the nursing home, said Christine Mueller, professor of nursing at the University of Minnesota at Minneapolis. (The other head of the steering committee, Dr. David Gifford, recently took a job with the AHCA as senior vice president of quality and regulatory affairs.)
Mueller notes that use of the NQF measures are strictly voluntary for anyone, including the CMS in its nursing home ratings. “It would make sense that CMS would want to use endorsed measures,” Mueller said. “They may not use all of them.”
Nevertheless, the AHCA would like all of the new measures to be put on provisional status until after some of the results become available, giving groups in the industry another chance to appeal the measures, and appealed to the NQF for that to happen. Currently, eight of the measures are endorsed on a time-limited basis pending further testing of the measures by the NQF.
“AHCA believes that NQF must designate all the measures with provisional approval,” Fitzler writes in the AHCA appeal. “It is difficult to appeal any measure until testing is completed and measure performance results have been analyzed, validated and published.” They will remain on time-limited endorsement until they have been tested.
Mueller said the measures that are not provisional are very similar to existing measures and aren’t expected to be very different from the measures used in MDS 2.0.
In addition, Castle said he’s not sure that it’s a limitation to focus on long-stay measures, given that most consumers are interested in long-stay results. “I would flip that and say to that criticism, ‘Would it make sense to have an equal number for both?’ ” he said. “I’m not sure that it would.” Some argue that while the NQF measures are well-designed for clinical evaluation, the inclusion of such clinical measures in consumer-focused ratings by the CMS can lead to misleading results. The updated measures “are appropriate,” said Mo Funk, chief operating officer of Miami Jewish Health Systems, a not-for-profit senior-care provider.
But he said they’d like to see use of the measures taken out of the Nursing Home Compare calculation and removed from the website because he’s not so sure that the connection to good nursing home care can be made from the quality measures.
For example, Miami Jewish is more than willing to accept patients with existing pressure ulcers, while other facilities may not be as willing to do so. “Sometimes they get worse,” and it hurts their numbers, Funk said. Because Miami Jewish would not turn down a patient because he or she has pressure ulcers, “in essence we get penalized for that,” he said.
“We should hold all of us to the highest standards we possibly can,” Funk said, but based on his experience, he sees a “disconnect” between the CMS ratings and reality. He said there are nursing home facilities he believes have poorer quality of care but receive higher star ratings than Miami Jewish’s four-star ratings on a five-star scale.
“I think they did a good job” with the measures, but “I don’t think this was built or intended to be a rating system,” Funk said.
Mary Kahn, a spokeswoman for the CMS, said testing and analysis of the measures are under way. The CMS plans to release the new data publicly in February. “We’re hopeful that these measures will be available for Nursing Home Compare, but have made no decision yet on their use,” she said. The current version includes 10 NQF-endorsed quality measures, seven related to long-stay residents and three to short-stay residents.
The measures also could take on greater significance if the federal government expands on value-based purchasing efforts for nursing. The CMS is almost halfway through a three-year demonstration project that began July 1, 2009, and aims to financially reward participating nursing homes that demonstrate high quality of care or improvement in care. That project includes eight Nursing Home Compare measures—five long-stay and three short-stay measures. The project also includes hospitalization rates, staffing data and survey deficiencies. When the demonstration began, there were more than 180 nursing homes participating in Arizona, New York and Wisconsin.
The CMS has some near-term changes in store for its Nursing Home Compare site. To make time to prepare and test the MDS 3.0 data, quality data and quality five-star ratings on the site were frozen on April 23 for six months, according to the CMS.
The CMS typically updates the data quarterly, but will leave current data covering MDS 2.0 data for the first three quarters on display until October. Also on April 23, new sections were added spelling out consumer rights and information that will allow consumers to more directly file complaints with state survey agencies.