Congress's watchful eye.

How widespread are the quality-of-care problems in nursing homes today, in your opinion? Do you think HCFA's survey data reflect reality?

Grassley: I rely on the General Accounting Office for reliable, objective assessments of the quality of nursing home care. In March, the GAO told our committee, "HCFA has not yet realized its main goal: to help ensure that homes maintain compliance with federal health care standards." The GAO found that more than one-fourth of the nursing homes nationwide had serious deficiencies--including inadequate prevention of pressure sores, failure to prevent accidents, and failure to assess residents' needs and provide appropriate care--that caused actual harm to residents or placed them at risk of death or serious injury. Most homes corrected deficiencies identified in an initial survey, but 40 percent of homes with serious deficiencies were repeat violators. Although the survey system may not capture all violations of federal standards, I have no reason to believe allegations that overzealous surveyors make frivolous citations. I asked the GAO to examine a package of allegations of frivolous citations of nursing homes by surveyors. The GAO concluded that the system worked appropriately, for the citations for which it had adequate information.

How would you rate HCFA's progress in improving care?

Grassley: HCFA has devoted significant resources to implementing new nursing home initiatives designed to improve the quality of care. They expect to finish putting the improved system in place during the year 2000. As of June 30, incomplete initiatives included redesigning the survey process to better identify violations of federal quality standards and redesigning the management information system to track violations of quality standards and to monitor enforcement and correction. HCFA is much closer to improving quality of care than when the agency started.

You have vowed to step up oversight of HCFA to ensure that plans are carried out. What are the most important next steps?

Grassley: The next, crucial step is for HCFA to be able to evaluate the results of its efforts. I expect to hold a hearing next summer to find out if these efforts have actually resulted in improved quality of care for nursing home residents. At the same time, HCFA must make the current enforcement process work so that penalties stick, fines are paid, and the poor nursing homes do not escape punishment for their violations. The enforcement process has teeth, but the teeth aren't biting as often as they should.

The survey process emphasizes the negative. Do you think it should be made easier for facilities that always do well, to focus resources on the poor performers?

Grassley: I don't agree that the survey process emphasizes the negative. It emphasizes compliance with the federal laws to protect nursing home residents. Extensive research into the quality of nursing home care during the past two years unfortunately shows that far too many homes still fail to meet federal standards of care. Furthermore, the system of monitoring and measuring the quality of care is inconsistent and imprecise. Until demonstrated improvements are made in the delivery of care and effectiveness of the system, it is too soon to begin re-engineering the survey system.

That said, it is important not to rule out new thinking about how to improve the system. Problem nursing homes often remain problem nursing homes. Diverting scrutiny from facilities with relatively unblemished survey records to those with a history of violations has not been tested. If such a proposal can demonstrate merit and credibility among key stakeholders interested in preserving quality of care in long term care, it must be tested--with great care.

Do you think Medicare and Medicaid payments to nursing homes are adequate to support quality care, especially in light of prospective payment?

Grassley: The evidence is slim that Balanced Budget Act payment changes are straining providers except in the rehabilitation cap and payments to skilled nursing facilities. With respect to the rehabilitation cap, I have introduced S 472, which would provide an exceptions process for patients requiring high-intensity care. With respect to prospective payment, there appears to be agreement that the system does not reimburse adequately for patients who need relatively high levels of non-therapy ancillary services and supplies. I believe Congress will address these problems.