ALEX KACIK Hello, and welcome to Modern Healthcare's Beyond the Byline, where reporters add context to their stories to help you better understand the news and how it's reported. My name's Alex Kacik. I'm the hospital operations reporter for Modern Healthcare. Today, we're lucky to have Ginger Christ, our post-acute and staffing reporter. Thanks for joining us, Ginger.
GINGER CHRIST Thanks so much for having me.
ALEX KACIK One of your stories looked at the Centers for Medicare and Medicaid Services claim that nursing homes with lower quality ratings were more likely to have COVID cases and related deaths. You went into some of the star ratings data with our data team and what you produced didn't exactly align with that claim, and that seems to underline the caution we as reporters must take with claims and arguments from the federal government as we process the data from this pandemic in real time. So I was hoping if you could take us through how you got started on that story and how it unfolded.
GINGER CHRIST Absolutely. So this story came out right after CMS started collecting nursing home data about the pandemic. Up until this point for the first few months of it, there was not any data being collected at the federal level. So when this report came out, announcing that first round of data, I wanted to look into that more and just see what we had there. First, CMS said that a facility that had a lower star rating in their star rating system was more likely to have COVID cases. So I thought that really seemed to stand out. I had written a story previously, during my time as a reporter in Ohio, looking at how loved ones and people could decide which nursing home should go to during the pandemic, because the things they normally would turn to, these star ratings, weren't necessarily something you maybe could look at in terms of pandemic response, because the data wasn't saying this is how a facility actually handled the pandemic.
It's older data. So I had that in the back of my mind when this data came out, and from that reporting, I had found that there was no correlation, at least in Ohio, from the data that had been collected at the state level. So I wanted to see if that carried through at the national level with this new data being collected. I asked our data journalist, Tim Broderick, to pull some of the data and start doing some charting to see if nursing homes with lower star ratings did have more cases of COVID.
What we found was that in the aggregate, so all nursing homes that have COVID cases, there was no correlation. You were just as likely to have a COVID case if you had a one-star rating, or if you had a five star rating, which is considered the paramount rating. However, CMS later clarified that when they were talking about nursing homes with lower ratings having more cases what they actually meant was more outbreaks. So in that case, data is true. If you're in that 90th percentile, which means you have a large outbreak of cases, there is a slight trend saying that facilities with one star ratings are in fact more likely.
ALEX KACIK Nursing homes are some of the hardest hit sectors. That share of the 90th percentile, is that a significant size in terms of that sample? I'm just trying to understand how CMS would be able to come out with this claim and try to justify it themselves.
GINGER CHRIST Yeah, so CMS focused their early attention on facilities that had large outbreaks. So it kind of makes sense that this is what they would be looking at in terms of data. However, it is a very small number when you look at that 90th percentile. By definition, it is the 90th percentile, so it is just a small sample size, and that's our job as reporters is to look at the data as a whole, look at what it can mean, and look at the different interpretations people are making with it, and then let the audience know and make decisions for themselves based on what we've learned.
Why is it important to differentiate here in terms of looking at data as a whole and aggregate, and then also looking at smaller swaths, but, ultimately what's the relevance of CMS coming out with this kind of statement? For a long time, skilled nursing facilities and long-term care facilities have been under the gun, so to speak, when it comes to certain task forces that come together on a state and federal level that try to investigate some quote/unquote, bad actors, and it seems that have this relatively punitive dynamic between regulators and providers. I'm just trying to understand and distill the importance here of trying to A) be transparent in what we found in our data and either give credence to some CMS claims or if what we find contradicts them, make sure that we make that distinction.
Sure. So the reason that it really mattered what a star rating a facility had, if that tied into COVID cases, is because CMS was penalizing and continues to penalize facilities that have infection control problems, or that they deem have infection control problems. So there are these normal inspections that take place in facilities, as you mentioned. Those were put on hold during the pandemic, and CMS started focusing in on facilities with large outbreaks, and then CMS started assessing penalties. As of August, there was something like $15 million in penalties, fined against nursing homes that were found to have infection control problems, so it becomes a big deal how you cut the data when you look at what the data is being used for.
ALEX KACIK As you referenced, Ginger, on March 3rd, Attorney General Barr came out with a national initiative, looking at infection control protocols at skilled nursing facilities. So to your point, it sounds like data like this could hold a lot of weight that may shape some of these investigations on a state and federal level into these facilities. So I imagine coming out with the most accurate and detailed and comprehensive information is pretty important,
GINGER CHRIST Right, and I mean, one thing to consider, too, is that nursing home data wasn't collected for the first few months of the pandemic. So when this data came out, there was a lot that was unknown about how COVID was spreading among nursing homes, and what was the cause of that. So CMS was saying, it was infection control issues, but experts and others in the field were saying, this is really tied to community spread and how many cases there are in a particular geography. So when you're looking at data like that, it's easy to maybe ignore other things in favor of something else. So you need to really understand what the data is being used for.
ALEX KACIK To your point, I was talking with a healthcare economist at Harvard, who said "If you are in an area with a large community spread, I don't think COVID has discriminated, whether you are in a five-star or one-star facility. Every facility needs help fighting this at a system level." I'm curious what experts thought of this correlation that CMS brought about too.
GINGER CHRIST So community spread as being tied to COVID cases and nursing homes is definitely something that we're starting to see recognized at the federal level as of late. There's been new testing guidance, that's been put out for nursing home residents and staff, and that's being tied to the community spread or the positivity rate in a community at this point. However, early on that was not the case, and so it was still a pretty bold statement to make that nursing home cases were tied to the community. That wasn't something that had necessarily been proven early on. Now that's something that's definitely being tied to nursing home reports and reviews.
ALEX KACIK As we hear a lot of scrutiny in terms of what we do, and as a whole, as a society, try to process some of this data in real time, what's our responsibility as journalists to try to fact-check some of these claims and what does this say about how we verify, or try to dispute some of these claims in our reporting process?
GINGER CHRIST Our role as journalists is to be watchdogs. A lot of people are being inundated with information right now. There's so much coming out during the pandemic and people don't know what to believe. It's our role as truth tellers to look at a claim and find the data behind it, to prove that it's true, or find the information or sources behind it to prove it's true. It's not enough just to say, oh, this organization said this. It must be true. It's our job to question every claim that is made so that when we report it, we're proving its accuracy.
GINGER CHRIST So especially now, when the fourth estate is being questioned, that's why it's so important to look into every claim that is made and be transparent with readers about how we got to that point or how we prove that thing true. I think something like this podcast comes in helpful because it lets readers know this is really how we got this information. This is the process that goes on behind the scenes. We've seen that even with reporting now, when we talk about anonymous sources. A lot of times there are very good reasons that reporters use anonymous sources, but to the public that can seem questionable. So in all aspects of reporting, the more truthful we can be, and the more we can use data to support what we're reporting, I think the greater benefit that we're providing to readers.
ALEX KACIK I hear you, and I think that transparency element goes a long way in these days. So the more we can do to prove our work and try to ensure that our fact-finding is sound and that we're using the right processes, seems a paramount in these times. Ginger, you mentioned that you've been watching some of the penalties that are being doled out as of August. I'm curious what else you're keeping tabs on going forward to try to monitor the situation and how COVID and the related consequences are unfolding in that post acute and longterm care sector.
GINGER CHRIST So the pandemic, it's no surprise, has been particularly difficult for post-acute care facilities, especially nursing homes. We know more about nursing homes because they receive federal funding. So they have to report their findings. That's why we don't hear as much about assisted living communities, even though they're having problems and struggling as well. So in trying to keep tabs on this industry and looking at a number of things, there are a lot of things coming from the federal government in terms of their response to the pandemic, and that includes rules about testing, how often testing needs to be done, surveillance testing, how often you're testing those who work in facilities, and those rules and regulations are changing in real time. So I'm constantly looking at what the administration is putting out and then checking in with providers and others in that space to see how that plays out to them. If they actually are getting the support they need, how they're being penalized, what that looks like.
ALEX KACIK Thank you so much for your time and your work and sharing your experience with us. It was helpful to get a behind the scenes at how this came together, and we appreciate you sharing your experience.
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