LONG-TERM CARE

Did feds jump gun by posting nursing home quality on Web?

Last month, the Centers for Medicare & Medicaid Services (CMS) announced the rollout of Web-posted quality measures for all Medicare- and Medicaid-certified nursing homes. Scarcely had it completed its press conference before the U.S. General Accounting Office, Congress' investigative arm, released its own 40-page report, chastising CMS for prematurely expanding the initiative before it had adequately evaluated data from the six-state pilot program launched in April (Drug Topics, May 20). GAO reported "serious concerns about the potential for public confusion by the quality information published."

Tom Clark, director of professional affairs at the American Society of Consultant Pharmacists, agreed that ideally it would have been better to wait. "But I understand CMS is under a lot of pressure to address quality issues in nursing homes. And feeling this approach is useful, it wanted to roll out [its report] as quickly as possible."

Defending the rollout, CMS administrator Tom Scully said, "Seventy percent of consumers in the test states responded on a rating scale of 1 to 10 that they found the consumer measures to be at least an 8 as far as helpfulness and quality of the measures."

The "public confusion" controversy stems partly, Clark said, from CMS' "deciding to call these things quality measures instead of quality indicators." By so doing, he explained, CMS is presenting the "measures" as being stronger than they really are. And will consumers read all the disclaimers? "Part of the concern is that people who use the Web site are going to look only at the numbers and then try to make some kind of assessment without clicking on all the links to read the background information. So there is a real potential for people to misunderstand how it works."

David W. Kazarian of Infuserve America, a consultant pharmacist in Florida, one of the pilot states, agreed with GAO. "I think it's about time we started looking at quality, but I'm not sure this is the best way to do it. Only time and tinkering with the system will tell. I absolutely feel the rollout was much too fast. More data should be collected, and there should be input from people using the data to see what they are thinking when they see the data."

Scott Wheeldon of NeighborCare in Englewood, Colo., another pilot state, concurred. "The facilities as well as the public need to become more familiar with the type of data reporting that's going into these postings. It will be hard for the consumer to access the information and really understand what it means."

Among the areas of concern is that the general public might not understand that facilities set up to handle certain problem areas, such as those with wound care units, may "look bad" in the measurement of pressure sores only because of the high number of patients with this problem they admit. When Drug Topics asked Scully about this, he replied, "The terrific nursing home that has a high level of bed sores probably has a damn good explanation for why that is; so in the bed sore category, for instance, we put in risk-adjusted and non-risk-adjusted [measures]. We believe in giving the consumers as many tools as we possibly can to measure the results, and we don't think it's going to be that confusing. But it certainly is possible."

That possibility is at the root of the concern. As Clark explained, "The facility admission profile is designed to help take into account these differences in patient population and to adjust the facilities' ranking to make them look better. But the research has not been really clear in terms of how effective that is. So the quality measures are being presented both ways, with and without the adjustment—the theory being that consumers can see it both ways and make their own assessments. But pressure sores are the kinds of things that sometimes take many months to resolve. And there is concern that facilities may decide not to admit people who have pressure sores because they know they're not going to be able to get the pressure sore resolved in time to prevent their scores from looking bad. Additional research would have been desirable to get a better handle on some of these issues."

But, Scully said, the bottom line is, "These measurements are accurate, they're fair, and they create public discussion. And 78% of the nursing homes in the six test states reported that they had actually made improvements in quality as a result of the measures."

Ready or not, CMS intends to review the quality of home health agencies next year, and then shortly thereafter, on a schedule not yet totally determined, move on to hospitals. Scully has tentatively selected the six states for the home health industry, and none of them is the same as the nursing home test states. "We're two months off, at least, before finalizing the measures for home health," he said.

Dana Cassell

The author is a writer based in New Hampshire.

Dana Cassell. Did feds jump gun by posting nursing home quality on Web?.

Drug Topics

2002;23:76.