Are "bad apples" good for you?

There's an old saying that, when life hands you a lemon, make lemonade. Or, to give equal time to another fruit, bad apples can be good for you.

The reasoning here is a little tortuous, but I hope worth it. As everyone knows, nursing homes have taken an unusually severe beating in the news media of late arising from quality-of-care issues. For instance, NBC News's coverage of the Grassley hearings in March (see "NH News Notes," p. 9) made it seem as though all 17,000 nursing homes are experiencing serious deficits in quality of care, although government witnesses themselves acknowledged that they were talking about a relatively small number of "bad apples" - maybe 5 to 9% of the total. That's more than enough; bad-apples facilities ought to be closed and their owners criminally prosecuted. Still, those percentages are a far cry from the "nursing homes as snake pit" imagery so popularly accepted these days.

So, yes, this is unfair to the majority of nursing homes - but so what? Look at it this way: This focus on the "bad apples" is diverting public attention away from hazards threatening perhaps five times as many facilities, with risks shared by patients and management alike. I am referring to the ongoing clinical experiment known as the Medicare Prospective Payment System (PPS).

As articles in this issue make clear, the PPS really is an experiment. The hypothesis being tested is that a withdrawal of at least $9 billion (or $16 billion, according to the Congressional Budget Office) from Medicare reimbursement for postacute care will leave quality of care unaffected and perhaps even improved, due to added cost-efficiency. Unfortunately, some early data (and a number of bitter off-the-record comments) indicate that precisely the opposite is happening. Care is getting worse, and costs threaten to go higher if any real improvements are made.

Explanations for this conundrum are reviewed in this issue. The bottom line, though, is - well, the bottom line. Healthcare is a profession, but it is also a business. And, when you change the rules by putting providers on a "business basis" (i.e., paying prices rather than cost-plus), they will act like businesses in crisis. Cutting costs takes precedence over everything, and that means Medicare postacute patients risk being clinically shortchanged.

How big a problem this might be it's too soon to say. There are ominous anecdotes being circulated out there, though, and a lot of concern among people in the know (including one policymaker who told me there was "no way I'd put a family member of mine in a SNF on a Part A Medicare stay"). Meanwhile, providers risk placing themselves in legal jeopardy simply by trying to stay in business.

In a previous editorial I indicated my admiration for providers who take a positive attitude on PPS and try to make it work as intended. I still do admire them. I hope that the "improved care" visions put forth by PPS proponents really do bear out, as SNFs become more accustomed to working under the new rules. But we and I do mean we Americans who might someday need postacute services - have a way to go before we can feel assured about this.

We will find out in due time whether PPS can work. In the meantime, let's give thanks to those unsuspecting Americans who are undergoing this experiment. And let's appreciate the media's coverage of the bad apples, which is at least diverting people's attention from the risks they really face.