Greetings from HCFA's new topsider.
As if nursing home owners and administrators didn't have enough to worry about, now one of their sharpest critics has become boss of HCFA, the Health Care Financing Administration which oversees Medicaid and Medicare. With Bruce Vladek in charge, should nursing home managers hunker down and (as usual) expect the worst? Was Vladek still the man who, 12 years ago, in a book called "Unloving Care: The Nursing Home Tragedy," concluded that nursing homes were overused, underskilled and too concerned with profit? The man who called for a 25% reduction in nursing home beds, a shift of ownership from for-profit to non-profit, and an emphasis on home- and community-based care? Is he, as many in nursing home leadership fear, The Enemy?
After listening to one of his debut performances before a long-term care audience, at a meeting on quality improvement sponsored by the Joint Commission on the Accreditation of Healthcare Organizations, it was difficult to be sure. Several of Vladek's remarks did raise serious questions about nursing homes' future. On the other hand, he had some nice things to say, as well -- for example, expressing a genuine appreciation of some of the progress they've made since his book was published. "The nursing home community is radically different from what it was in the 1970s," he said. "I'm struck by how much things have changed. We have come a long way since then."
He emphasized as a "great success story" the 50% reduction in physical restraint use that nursing homes have achieved in recent years. That translated, he noted, to 320,000 fewer residents in physical restraints than five years ago. Reduction in chemical restraints, another OBRA-inspired project, is still in its "pilot stages," he said, but results are so far encouraging. Furthermore, as of last summer, all residents in the nation had undergone complete assessment, as called for by OBRA.
Vladek observed that there had been progress in staff education, as well, "though this is slower and more complicated."
From there, though, things got a little shakier, from nursing homes' standpoint. Vladek spoke approvingly of the "remarkable job" done by the states in building community-based services, adding that in 1992, Medicaid supported some 400,000 people receiving home health care, as well as 1.5 million nursing home residents. He saw this as a welcome response to his finding, in "Unloving Care," that one-third of nursing home admissions were inappropriately-placed "social admissions," i.e. these residents didn't really need nursing home services but had no place else to go. The bias of the Clinton Administration toward home- and community-based services is well known.
Vladek did acknowledge, though, that nursing homes are admitting sicker residents than before and face greater clinical challenges. But this did not, perhaps surprisingly, amount to an endorsement of nursing homes moving toward more sub-acute care, a very lively trend these days. Vladek sounded as though he viewed this as just another case of misplaced financial resources due to "our 15-year mania for closing hospital beds." The sub-acute trend, in his view, is "a private market response" to a lack of careful government planning for treating these patients. In his view, the onus was on government to come up with a planned approach, including possibly using existing hospital overcapacity. Getting hospitals back into the sub-acute act, perhaps at a substantially reduced per diem, may or may not be enlightened public policy, but it would most definitely not be welcome news for nursing homes that have already devoted substantial resources to this.
Vladek also foresaw a development of specialized chronic care facilities to take care of specific conditions other than those that are geriatric-related, such as AIDS. "It really is not good care to scatter AIDS patients among nursing homes throughout the country," he said, adding, "we need alternatives." (This may or may not be good news for nursing homes, depending on their point of view and need for alternative funding sources.)
What about his earlier recommendations for a 25% reduction in nursing home beds and a shift from for-profit to non-profit ownership? Vladek was asked about those and responded that demographics -- the increasing number of elderly -- had pretty much taken care of the former. As for the latter, he had nothing specific to say, but did suggest that the concept of the freestanding nursing facility without formal involvement with the rest of the long-term care system may have become "inappropriate." Perhaps the most reassuring thing he said on this score was that nursing homes' place in the overall scheme of things, including financial ownership, "will be a long time working out."
In short, Vladek sounded as though he has substantially moderated his views about nursing homes since his "Unloving Care" days, but remained unsure about their future role -- an uncertainty that is echoed these days in many quarters. And, for the really positive-minded, you can look at it this way: HCFA has, at last, an administrator who knows something about nursing homes -- the basis for a working relationship.
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|Title Annotation:||Health Care Financing Administration|
|Author:||Peck, Richard L.|
|Date:||Oct 1, 1993|
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