The past several years have seen sweeping overhauls of nursing home enforcement on the federal level, and the Medicare program’s top clinical officer says her agency isn’t done beefing up its efforts.
Dr. Kate Goodrich, the chief medical officer for the Centers for Medicare & Medicaid Services (CMS), promised that more changes are coming to a variety of skilled nursing facility oversight programs — from expanded information on the consumer-facing Nursing Home Compare website to potential new quality measures regarding SNF safety.
Goodrich gave these regulatory signals on the most recent episode of “Rethink,” SNN’s twice-monthly podcast series featuring interviews with top thinkers and leaders in the post-acute and long-term care space. Edited and condensed excerpts from our conversation are presented below; you can also listen to the full episode on a variety of podcast services. And if you like what you hear, make sure you subscribe so you won’t miss any future episodes.
What’s behind this recent enforcement push? Were there any specific events that prompted it?
I would say it’s a combination of things. Nursing homes are a little bit different from the other facility types that we regulate or oversee, in that a significant number of people who are in nursing homes — that’s their home. They’re residents. They’re not just patients. They actually reside there.
Obviously, there’s some who are patients, who are there for a shorter period of time, but because this is where people live, we believe really strongly that residents deserve to be treated with dignity and to be kept safe from abuse and neglect, and to have the highest quality of care possible.
Over the last several months, we began working on a really comprehensive strategy that pulled together all of the different things that we were either already doing or were considering doing, to really strengthen the quality of care for residents and patients within nursing homes or skilled nursing facilities.
You saw us talk about and publish on our five-part plan, which focuses on strengthening oversight, enhancing enforcement, increasing transparency, improving quality, and putting patients over paperwork.
I would also say, of course, there’s been a lot about nursing homes out in the public sphere as well, for a variety of reasons. The timing coalesced with us already doing a lot of work in this space. And the timing was really good with all of the things we’ve been hearing in the news — whether it’s related to disasters after hurricanes, what unfortunately happened after Hurricane Irma down in Florida — or some of the issues around abuse and neglect.
We’re very grateful to Sens. Grassley and Wyden for their focus on strengthening the quality and safety of care in nursing homes through their public hearings. All of this kind of came together at the same time, and we are just super excited to be doing this work.
My stint covering the industry had just started back in 2017 when Hurricane Irma struck, and enforcement and oversight have been a continued theme since then. Aside from what you have going on, are you looking at future oversight changes?
Absolutely. We’ve been working for a little while on strengthening our oversight of the state survey agencies — who are the boots-on-the-ground people, who go in and inspect nursing homes at least once a year and when there is a complaint about a nursing home.
But we know that there’s been some inconsistencies in how certain aspects of that survey process go, and how findings may be cited and so forth. We’ve been really, really focused on trying to improve that consistency and transparency around the process. We’ll be able to say a little more about that hopefully later this year, about ways in which we are really strengthening our oversight of those state agencies. So that’s number one.
[[Editor’s Note: After this interview was conducted, CMS administrator Seema Verma released a blog post in which she discussed some of the agency’s goals for state survey improvements.]]
On the enforcement side, you may recall — probably about a year before you started covering this industry — we published an overhaul of the Requirements of Participation, the minimum health and safety standards that nursing homes and long-term care facilities have to adhere to in order to be part of the Medicare program.
This was published in October of 2016. Because it is an overhaul, we knew that we couldn’t implement it all at once; that would be too much for nursing homes to have to deal with at one time, so we implemented it in three phases. We’ve implemented Phase 1 and Phase 2, and the last phase is Phase 3. Nursing homes will have to adhere to the safety requirements as of November of this year.
We’re excited about this one, because this last phase in particular addresses an issue that is so critical for nursing home residents — and that is infection control. We have requirements that nursing homes must develop infection control programs. And the reason we’re focused on that so much, and why we really wanted to work with advocates and the industry to really get these guidances right, is because the number-one reason that nursing home residents get admitted to the hospital is because of a health care acquired infection. So infection control is really a very, very critical safety issue within nursing homes. Those requirements will be in place in November of this year, and our state survey agencies will start surveying to them after that.
Three more things to mention. One is around increasing transparency. We’re continuously looking for ways to improve our Nursing Home Compare website. We know people really like the star ratings; however, we also have heard that there are aspects to the website that are difficult for people to understand. We’ve also heard that people would like to see certain aspects of care quality more brought up to the forefront — and easier to understand right upfront. We’ve been doing some work to look at ways to make that site much more user-friendly.
I can’t really say exactly what we’ll be doing later this year and early next, but you will see some changes that are intended to be directly responsive to the understandability of the information that’s on the site.
We have heard from stakeholders that they would really like to see more quality measures around safety within nursing homes. We do have some that are around safety, but this is probably a portfolio of measures that could be built out in that area little bit more. We are working on developing an all-cause harm measure, if you will, for safety within skilled nursing facilities.
And then finally, for Patients Over Paperwork, we published our long-term care rule in July of this year, which is focused on finding ways to reduce the administrative burdens that nursing homes face — that are not really contributing to improving the quality and safety of care. There definitely were some areas where we felt like: If we could eliminate some of the requirements that were duplicative, that would give nursing homes a little more flexibility, and give them some hours back, so that they can spend that time taking care of patients.
Specifically around Nursing Home Compare, operators and investors often tell me that it doesn’t accurately capture intangibles — thus prompting some prospective residents or families to use Yelp or Google reviews. Is CMS looking to add information like that to the site?
I think this is important. I think this is exactly what families and caregivers and residents themselves want to see. So I totally understand where folks are coming from, and agree that that would be really, really useful.
I’m glad there is a Yelp. I’m glad that there are other tools out there. Certainly people have asked us to have that kind of information in the same place as the other quality information that they currently receive on Nursing Home Compare. We are definitely interested in exploring and reporting residents’ experience or satisfaction, and looking at different ways in which we can do this.
It is actually a fairly complex process to undertake, because you of course are capturing the resident or the caregiver’s voice, and we want to be sure that we’re doing that in a way that is accurate and fair — and yet truthful, and gives the information people are looking for. In order to do this, it would require us undertaking a very methodological and deliberate process that, frankly, would take some time.
There’s a couple of ways to do this. In many of our other quality programs, we have patient experience surveys that we administer and the responses get translated into quality measures — HCAHPS for hospitals and the In-Center Hemodialysis CAHPS, that kind of thing.
There’s a very rigorous science behind developing those kinds surveys and the quality measures that are derived from them. So that is something that we are looking into, but it certainly would take some time.
Regarding the Yelp idea, this is something we’ve actually been thinking about for a long time in a variety of settings of care — not just nursing homes. There actually has been some research that’s been done looking at this — and how you can do this, again, in a scientifically rigorous way but that captures that qualitative, subjective information that people give.
What I would say is: We are continuing to actively explore that for, quite frankly, all of our Compare sites, not just Nursing Home Compare, and we really are tracking closely the research and literature in this area.
I’m happy to say that there’s a number of providers in the United States that actually are already doing this on their own. So we’re trying to learn from their experience as well, to see how we could potentially apply that on a national scale.
Are there any plans to delay enforcement of certain parts of the third phase of the RoPs, as there was with Phase 2?
We aren’t anticipating making any changes to our enforcement remedies for Phase 3, so at this time, we do not have any plans to implement a moratorium on the enforcement tools for Phase 3.
Some states have embraced transparency around ownership of nursing homes — for instance, Kansas’s new law in the wake of the Skyline Healthcare collapse. Is that something that CMS is exploring, or is it a state-level issue?
We do certainly think — and we’ve certainly seen evidence — that ownership plays into ensuring that nursing homes keep their residents safe. I would certainly agree with you on that.
We are looking for ways to make sure that there is consistent quality and safety in these facilities by improving our oversight and transparency. To that end, we proposed new regulations that implement additional provider enrollment provisions that are related to requirements under the Affordable Care Act — that help to make certain that entities and individuals who pose risks to the Medicare program and our beneficiaries are kept out of — or are removed, in fact — from the Medicare program.
So the Program Integrity Enhancements to the Provider Enrollment Process proposed rule — this would require that health care providers and suppliers must report affiliations with entities and individuals that ether have uncollected debt to Medicare, Medicaid, or CHIP; they have been or are subject to a payment suspension under a federal health care program, or they’re subject to an OIG exclusion; or they’ve had their Medicare, Medicaid, or CHIP enrollment denied or revoked.
CMS can deny or revoke those providers’ or suppliers’ Medicare, Medicaid, or CHIP enrollment if we determine that the affiliation poses an undue risk of fraud, waste, or abuse under this proposed rule.
I will say that this is a rule is in the Center of Program Integrity. It’s not directly in my shop.
Even as reporters and editors covering this industry, it’s hard to determine who owns nursing homes — I know it’s a frequently necessary liability strategy for operators, as AHCA CEO Mark Parkinson told me recently, but it also makes it difficult to track ownership.
I understand, and this is something that we’ve certainly heard concerns about. We always have to look at what our statutory authority is for what we actually can make public.
We understand that this is definitely an issue that people are concerned about — and trying to address it, at least for now, in the way that I described through this proposed rule.
How close are we to a site-neutral payment system? There’s a lot of chatter about how the Patient-Driven Payment Model (PDPM) is a stepping stone toward that.
The IMPACT Act really, I think, tried to lay the foundation for potentially ultimately going to a unified post-acute care PPS system, which you can think of as a site-neutral-type system. I think that’s what the IMPACT Act was trying to do — was to lay that foundation to be able to do that.
In order to fully go into a site-neutral system for post-acute care, we would require Congressional action for that to happen. But obviously it’s something that this administration is very interested in. We’ve taken a number of steps to move toward site neutrality in a number of other ways. I think we have a lot of information in our Outpatient Prospective Payment System rule this year around that … but it’s not focused on post-acute care. It’s really on other settings of care.
This is definitely a topic of great interest for this administration, with the IMPACT Act — which we’ve really almost fully implemented at this point. We’ve made our final proposals for implementation in our payment rules this year for the final data elements and quality measures that really are now standardized across all those settings of care. You really can feel confident that we’re able to assess, let’s say, functional status the same across home health agencies, skilled nursing facilities, inpatient rehab facilities, and long-term acute care hospitals — which we were doing in wildly different ways previously.
But now we actually can assess all of these things and collect data the same way across all of these facilities — data that would be important to make payment determinations, and for measuring quality and for survey and certification.
What does the skilled nursing industry look like in the future?
It’s pretty hard to predict what the nursing home industry is going to look like in 10 years. We’re taking a number of steps now, through some pretty significant policy and program changes that we think will have both an immediate but also a long-lasting impact on the care of nursing home residents and patients who are in skilled nursing.
The whole health care payment system is changing to pay for value. That hasn’t caught up as much yet in the post-acute care space — again, that’s where we would need some help from Congress to be able to do that. We don’t have value-based care arrangements — except for the SNF Value-Based Purchasing program — in the post-acute care space.
The train is out of the station on value-based care for sure. But this is a 30- to 40-year trajectory that began, I don’t know, five to 10 years ago, to pay for value. I think as the payment system changes over time, where you’re really focused on total cost of care and better outcomes for patients, that naturally the industry is going to evolve with that.
My hope for the next 10 years for the nursing home industry is what it would be for your relatives who may reside in one of these facilities: free from harm, free from abuse, being treated with dignity and respect, and that the quality of care that’s delivered is as good as it can be in as many nursing facilities as possible.
That’s a little pie in the sky, but if you’ve ever had a loved one in a nursing home or in a skilled nursing facility — and I’ve had both, I’ve had family members who have both been there as residents and there for 30 days or so after a hospitalization — you know that there’s still a need for care to be improved.
There are some very, very good facilities, but there are ones that still struggle. So we’re really trying to lift all boats through our current policy changes and program changes, because we really think that everybody deserves the highest-quality care possible.