Insights in Aged-Care Policy From "Down Under," Part 2.

Prospective payment and quality monitoring--a different game

In a previous issue of Nursing Homes/Long Term Care Management (June 2001, page 58), I discussed Australia's approach to structuring and financing what they call extended care, and compared and constrasted this with the American approach. Similarly interesting contrasts exist in their post-acute care payment system and facility accreditation process.

RUG vs RCS 

The Australian equivalent of the American RUG system is the Residential Care Subsidy (RCS) classification system. The RCS reimbursement form has only 21 questions, perhaps because most elderly with complex medical needs, such as ventilator care, are cared for in hospitals, not nursing homes. On the RCS, each question is individually weighted, presumably to gauge how much it impacts the actual cost of providing care. The instrument includes medical questions, such as episodes of incontinence (which is weighted high), as well as social questions, such as staff time spent with residents' family and friends (which is weighted low). The final result places the resident in one of eight (as opposed to the RUG system's 44) reimbursement categories. The first four categories classify a person as a hostel-level resident, and the second four classify a person as qualified for nursing home-level care. Using the RCS for both hostel and nursing home reimbursement is another key step the country has taken toward moving the se two residential care types closer together.

To check the accuracy and consistency in the way providers classify residents, government evaluators visit every year. Some providers have complained that this is a process that focuses only on having the documentation sufficient to support the RCS classification. "They only look at your paperwork, not at the resident," Joanne Martin, the director of nursing at Albany Gardens Nursing Centre in Brisbane, said. "It might be obvious that the classification is correct, but if a facility is not keeping up appropriate documentation to support it, the evaluators will downgrade your classification."

This sentiment about regulation probably sounds familiar to American providers. The financing system, though, might not. Interestingly, although both the United States and Australia collect an almost identical portion of their respective gross domestic products (GDPs) as taxes (not quite 30%), healthcare expenditures in the United States are much higher (13.5% of GDP vs 8.4%, and $3,925 per person vs $1,805 per person), while access is much more limited than Australia's 100%.

Accreditation Process

Quality monitoring is conducted in Australia in a manner that might be familiar to American facilities that have undergone Joint Commission on Accreditation of Healthcare Organizations (JCAHO) inspection, but on a much broader scale. Australia was just completing its first year of a new residential care accreditation process when I visited. Ali facilities had to be accredited by January 1, 2001, to continue receiving government funding. As of January 1, only one of Australia's 2,950 nursing homes had not been accredited--and would no longer receive government funds--and 20 had received a six-month provisional accreditation; 190 nursing homes had gone out of business because of the cost of the accreditation process.

Australia's accreditation system, which emphasizes the continuous quality improvement philosophy, is organized into four areas: Management Systems, Staffing and Organizational Development; Health and Personal Care; Residential Lifestyle; and Physical Environment and Safe Systems.

Each accreditation standard is rated on a four-point scale as commendable, satisfactory, nonsatisfactory or critical. Interestingly, providers could actually receive positive ratings for the quality of care they provide. Staff complete the facility's assessments, and then auditors come in to verify the staff's work.

Auditors can grant facilities a maximum of three years of accreditation. However, they can also grant shorter accreditation times, usually for one year, if they find problems (or even six months for those 20 "problem" facilities previously mentioned). They can also schedule "support visits" more frequently to check on facilities' progress in overcoming concerns.

One aspect of the new requirements involves the quality of the physical plants. Physical plants had to meet more stringent requirements beginning in 1999 and have to be completely certified by 2006. Many providers I visited told me how expensive it was to make the required changes. No one said it was unnecessary. Indeed, for the providers I spoke with, resident quality of life was important. More general evidence of this was the attendance by providers nationwide at a three-day training session in the Eden Alternative, sponsored by the Aged Care Queensland Association.

Almost everyone expressed familiar concerns about the consistency and subjectiveness of the accreditation process. "Everyone in Victoria is getting commendables," one Queensland-based provider told me. While some people I talked to felt that the system lacked any systematic way to address these inconsistencies in the future, others were optimistic that the system would be improved. Royce Voss, an administrator with Anglican Care of the Aged, said that he would be arguing that the accreditation system itself needed to incorporate some of the continuous quality improvement philosophy it was stressing with providers.

However, despite its flaws, there was widespread agreement that the system was better than the more punitive and inconsistent system that it had replaced. The old system was based on spot checks by authorities in response to complaints by residents or families. I was told that usually the situation had to be notably bad before the government would take any action.

Gillian Smith, the administrator at Avery Gardens in Coolangatta, said, "The major difference I have seen the accreditation process make is that all the staff, from housekeeping to the director of nursing, are focused on how they can improve quality. Now everyone is pulling in the same direction."

Conclusion

Looking at another country's health policy can provide needed perspective on our own. I left with a couple of particularly strong impressions. First, I was a little taken aback the second time someone pointed out to me that healthcare was a basic human right, which reminded me that not every country treats it as a commodity to be bought and sold. Second, although the Australian system is undergoing change comparable in impact to the change under way in the United States, providers and others working in aged-care policy seemed to feel that the system had improved in recent years and was likely to continue to improve. They're in a far different mood from providers in the United States, who often feel that the only ray of hope for the future of long-term care policy is that it can't get much worse than it is now.

Robert Greenwood was, at the time of this writing, Public information specialist for the American Association of Homes and Services for the Aging. Currently, he is director of public affairs for the National PACE Association, Alexandria, Virginia.