LTC Bullet--The CMS Quality Oxymoron

Tuesday, November 12, 2002

Honolulu, Hawaii--

LTC Comment: Jumbo shrimp, military intelligence, and now, the CMS Nursing Home Quality Initiative. OK, give the feds credit for trying. But "you can't make a silk purse out of a sow's ear," as Robert Vande Merwe's commentary after the ***news*** clearly indicates. "You get what you pay for" and the federal government sure isn't paying for quality nursing home care. Read this Bullet and understand much better what the nursing home industry is up against.

*** It's not too late to debate, recreate, and educate. We've tipped you already to "The Great LTC Debates," coming November 17 to 19, 2002 in St. Louis. At latest count, 400 of the nation's leading LTCi producers and marketing specialists will be there. And, you can still get the $50 discount. Just write "Center LTCF" in the RED SUBTOTAL box on the printable registration form and your cost will be only $380. Get all the details online. Go to for the conference brochure and registration form and to for the full line-up of sessions and speakers. ***

*** Furthermore, you can attend one of the Center for Long-Term Care Financing's highly acclaimed LTC Graduate Seminars immediately after "The Great LTC Debates" and in the same St. Louis hotel on November 20. Attend both programs and save another $25 (otherwise the Grad Seminar is $225). Seven Missouri continuing education credits are already approved and we'll give you a letter of completion to submit to other states to request reciprocal CEU credits. Hit reply and let us know to hold a place at the LTC Graduate Seminar for you or call Amy McDougall right now at 425-377-9500. Go to for all the details. Pre-registration is necessary so please act now to reserve your place. ***


What follows is a news story that describes the new Centers for Medicare and Medicaid Services (CMS) Quality Initiative and an editorial commentary about the program by an LTC trade association executive director. Although the commentary references Idaho, its message applies nationwide.

"CMS Sets Date for National Quality Initiative Debut. BALTIMORE, MD, Oct. 23 (Eli Digital) The Centers for Medicare & Medicaid Services has set a firm date for the nationwide unveiling of the Nursing Home Quality Initiative. 'The press conference will be held Nov. 12, and newspaper ads in all 50 states will run the following day,' a CMS source tells Eli. The agency will run full-page ads reporting the quality measures for the 50 largest nursing homes in each of 65 metropolitan areas across the country. CMS originally scheduled the rollout for October, but decided to push the project back until after the November elections in order to keep it from becoming politicized. The initiative is scoring all Medicare- and Medicaid-certified facilities on six chronic and four post-acute quality measures derived from the minimum data set. CMS will post facilities' scores for the quality measures on its Nursing Home Compare Web site at ."

Source: LTC Daily Analysis Briefs, October 23, 2002, prepared by for members of

"The CMS Quality Oxymoron"

by Robert Vande Merwe, Executive Director, Idaho Health Care Association

On November 12th the federal Centers for Medicare and Medicaid Services (CMS) will unveil a web site that gives consumers more information about nursing homes in their area. The Nursing Home Quality Initiative (NHQI) will post data on the Internet on ten different indicators intended to reflect quality of care for nursing homes certified by Medicare and Medicaid. Further, the information of 50 different nursing homes throughout Idaho will be posted in the Idaho Statesman on Wednesday, November 13.

It is ironic that CMS would roll out a quality improvement program for nursing homes within one month of a 10% cut in Medicare nursing home reimbursement. Worse yet, Medicaid pays on average approximately $9 per day LESS than the actual cost of care. The best thing that could be done to improve quality in nursing homes would be to restore Medicare funding and improve Medicaid funding to nursing homes.

The federal government has never been willing to pay for quality nursing home care. Medicare only pays for very short stays in nursing homes, and Medicaid, which pays for over 60% of nursing home patients, is health-care welfare. CMS has even identified ideal staffing ratios that would certainly increase the quality of care in nursing homes, but then refused to increase reimbursement to pay for more staff.

Therefore, Congress should also create an--above the line--tax deduction for premiums paid for LTC insurance policies. This would create an incentive for individuals to plan for their own care rather than wait for Medicaid to provide for them. Nursing homes would then compete in the market place for private pay patients, who are funded by their LTC Insurance policies. This would certainly increase quality of care in nursing homes more than cutting reimbursement while publishing potentially confusing quality measures.

While the public reporting measures are not yet perfect, the new Quality Initiative does get us started on the road to being judged by standardized, research-based information. We still have a lot to learn about measuring quality in health care and about using that information to provide consumers with reliable information, but I'm hopeful that this initiative signals a new era in quality for nursing homes. It's the right thing to do and itís a good first step.

Another part of the NHQI involves a technical assistance program by Qualis Health, Idahoís Quality Improvement Organization (QIO). Over the next several years Qualis Health will begin working with nursing homes to adopt more effective care practices, expand their quality improvement strategies, and continually improve care outcomes. This is an exciting paradigm shift. This new Federal program provides consultation to help improve quality rather than a big stick from Washington D.C. that demoralizes nursing home employees already overworked and underpaid.

CMS administrator Tom Scully has cautioned that the web-posted measures are not report cards, but one of many pieces of information that should be used in decision-making. Different nursing homes admit different types of residents. Some facilities serve sicker, frailer residents or admit a higher-than-average proportion of residents with conditions measured under this initiative, which could make them appear "worse."

This initiative does include a risk adjustment--not a health care term--to provide greater accuracy in compiling and reporting quality measures. In a complex formula, CMS applies facility and patient risk adjusters to the quality measures to account for a facilityís admission practices or profile. That is, if a facility specializes in wound care, this specialization is taken into consideration. The high prevalence of pressure ulcers may be adjusted somewhat to reflect a facilityís admission profile. Not all measures have a "risk-adjustment" nor have the complex formulas been perfected. Nevertheless the program will go forward.

People should use this information as a springboard for questions to ask. There may very well be legitimate and easily-explained reasons why a facility appears to have higher or lower than average rates of a particular measure that do not signal poor quality. Some facilities do have care problems. What counts most is the nature, degree and duration of any problem, as well as how the facility responds to correct them and ensure they do not recur.

Consumers should consider other information when choosing a nursing home, including cleanliness, reputation, recommendations of doctors, clergy and other families, and staff interaction with residents. There is no substitute for visits to nursing facilities and face-to-face discussions with caregivers to gauge quality of care and quality of life.

This information is just one of many tools for the public to use. It's similar to the way many people choose a college: Families don't rely solely on a single set of test scores or published rankings because numbers alone do not paint the entire picture of quality. Neither would we buy a car or a house without asking questions. We owe it to our loved ones to ask questions before choosing a nursing home.