Dr. David Grabowski on the Best and Worst of Nursing Home Reform
The Professor of Healthcare Policy at Harvard Medical School talks to Nancy Griffin about the opportunities and challenges in long-term and post-acute care.
Nancy: Tell us about your background.
David: I'm a professor of Health Care policy at Harvard University where my primary role is studying the economics of aging. Much of my research focuses on older adults and their long-term care and health care services and how they fit together. Care is quite fragmented in this population, so usually they don’t fit together very well.
I'm especially interested in individuals who have both Medicare and Medicaid coverage—those who are most frail and vulnerable in our healthcare system. I've spent over two decades doing research on this population.
In addition to my research, I also wear some policy hats. I'm a member of the Medicare payment advisory commission or Medpac, advising the US Congress on Medicare policy issues. Recently, I was part of the Centers for Medicare & Medicaid Services (CMS)’s Coronavirus Commission on Safety and Quality in Nursing Homes, making a series of recommendations to policymakers that provided a roadmap out of the pandemic for nursing homes. Even more recently, I was part of a National Academies of Sciences Engineering and Medicine Commission that made sweeping recommendations for the long-term reform of nursing homes.
So I both think about short-term, How do we get out of this pandemic? and longer-term, How do we fix the problems that have plagued this industry for decades?
Nancy: Tell us about how the pandemic changed the issues around nursing home reform and policy, and how they're being addressed.
David: Issues surrounding nursing homes have been around a long time. One of my colleagues said, “COVID-19 is a crisis on top of a crisis.” What the pandemic really did for nursing homes was (and this line is from an interview we did as part of that National Academies Report by one of the family caregivers), “COVID lifted the veil on social ills that that have been present for four decades.” Part of the reason we haven’t focused on this population is ageism. We haven't been willing to face growing old, so we put it out of sight, out of mind. The pandemic forced us to address these issues head-on and think about nursing homes from a policy perspective.
This sector has never received more attention than it has over the last several years. Some of that's good, and we are talking right now about big reforms that are encouraging. However, there's been a lot of finger-pointing and some of that is ageism. We were not willing to step up and put the resources in place very early on in the pandemic for protective equipment, testing and additional staff wages. At the high level, we have seen the best and the worst of behaviors towards nursing homes during the pandemic. There's a lot more attention and that's positive, but we've seen glaring examples of this group not getting the policy attention they require.
Nancy: You have identified two major challenges in long-term care and post-acute care. What are they and what do you see as possible solutions?
David: We need to rethink what we spend on long-term care and post-acute care services, and how we spend those dollars. We underfund in a lot of settings and, ultimately, we spend money on the wrong things.
Let's take each of those in turn. The first part is the underfunding issue. Medicaid is the dominant payer of long-term care services in the U.S. That is true in nursing homes and home-and-community-based services. They tend to not fund assisted living services. We also have a huge waitlist for Medicaid and home-and community-based services.
We know that Medicaid underfunds nursing home care. We need to pay more, but that's only part of the problem. Also, we don't have enough accountability for how public funds are being spent. There's a lot of private equity and for-profit owners on the nursing home side who aren't good stewards of our public dollars. So there tends to be a lot of tension among stakeholders. We need more money in the system, but also greater accountability.
The second part, spending money on the wrong things, has to do with how we are spending money in nursing homes. Historically we're spending our money on the institution-dominated long-term care system and post-acute care system. We haven't bonded enough services out in the community. We should think about transitioning more of our budgets away from nursing homes and towards home and community-based services. The Biden Administration tried early on to put more money into home-and-community-based services. Unfortunately, that effort died. I don't think we're going to see big expansions in the short term in home and community-based care.
I'm not one of those people who says we should pull every individual out of nursing homes. Even the best long-term care systems in the world, in places like the Netherlands, Switzerland and Sweden, have nursing homes. They just have better nursing homes than we do—better paid staff, smaller home models with single occupancy rooms. We can do so much better by our older adults and their families in terms of restructuring what a nursing home looks like.
I did a large-scale evaluation on the Greenhouse Project about a decade ago. I'm certain many of your readers are familiar with this small nursing home model. Residents have their own room, which is really a home. They control when they get up and when they eat. You must knock to go into their room. It's a resident-centered model. The staff are also empowered in this model. It takes the traditional nursing home and flips it on its head. That's what I mean when I say we're spending money on the wrong things. We need greater investment in these types of models.
Nancy: You mentioned in a previous conversation that there are some silver linings in the pandemic in terms of taking care of our workforce.
David: This is an area where we have so much more work left to do, but we've made great progress in terms of supporting the workforce. Wages went up during the pandemic more so than any other healthcare jobs. We've seen a lot of workers leave the profession. We need to continue to invest in terms of pay and benefits to recruit and retain the next generation of workers.
I would also add that it's more than just pay. I like to say pay is necessary but not sufficient. What many of these staff members want is a better culture and working conditions. Greenhouse is a great example of this as they were able to retain their workers during the pandemic. Those buildings are still really well staffed because the workforce is empowered, supported and valued. We don’t acknowledge our workers nationally at that level. A nursing home is only as good as the staff working there.
There's currently a staffing crisis around the country. As I said earlier, lots of workers have left the profession. I want to see an “all hands on deck” approach. I know the Biden Administration is considering a minimum staffing standard that would hold nursing homes’ “feet to the fire,” making certain they are sufficiently staffed. The only way we're going to get out of this is with better pay and working conditions. One idea is government-funded career ladders such as allowing CNAs to get their training to become LPNs. It’s going to take a public and private partnership to improve these jobs: the government to ensure the dollars are in the system to pay individuals and on the other side, the providers to step up and make this a job worth having.
Nancy: Talk to us about the recent nursing home reforms and if you think that they will legitimately improve access and outcomes.
David: I touched on the one that's receiving the most attention and that's the minimum staffing standards. We still don't know what exactly those will look like. Obviously the devil is in the details. The administration is currently studying what the standards should be like. In a vacuum, it's a very exciting development and one that has the potential to transform nursing home care. Putting more staff in the buildings is going to generate better outcomes. The great unknown here is how will this be paid for.
Going back to my earlier comments, nursing homes with a high number of residents on Medicaid are going to be challenged to meet a staffing standard. We also have facilities that haven't historically been putting all their dollars back into direct resident care and are playing fiscal games. It's going to be really interesting to see how that plays out.
The other two big reforms that the Biden Administration has been pushing forward are greater transparency around ownership and financial transparency about how providers are spending the money. That's going to be important. Ownership have been sharing more information on how facilities are owned and structured, and there will be more information on how the dollars are flowing The last piece that the Biden Administration has been pursuing has been increased regulatory oversight to make certain facilities are accountable.
Once again I step back and say I think that in a in a vacuum all three of these steps are positive ones. Collectively they are a step in the right direction. I just wish they were a little bit broader. What we really need is system reform rather than these smaller steps.
Nancy: Does data exist on the differences in care between profit and nonprofit nursing homes?
David: Yes, it certainly does. Nonprofits tend to be higher quality providers. However, nonprofits play an interesting role in the nursing home sector. My colleagues often have the idea that the nonprofits are the safety nets filling in the gaps and it's really the opposite, the nonprofits are our top providers. They tend to have more private pay residents, charge higher prices and are located in wealthier areas. So it's not quite apples-to-apples. Yes, they're strong providers, but they're not always taking the same populations as the for-profits and that's part of the problem. How do we encourage greater nonprofit entry in some of these underserved areas?
Clearly, it’s better for older adults to have money, good information and an engaged family, but those often aren't enough to overcome a broken system. Other countries around the world do a much better job of integrating older adults into society. Japan, for example, doesn’t have nursing homes that are separate from the rest of the society; they're integrated. It is not a place where someone goes to die; it's where they go to live alongside the rest of us. That interconnectedness is missing here in the US. That's what makes these reform efforts so challenging. We're advocating for a set of reforms, but it's not clear that society has come to terms with a lot of this.
Nancy: What gets you most excited these day?
David: I am quite excited by all of the interest right now in trying to change things, even though it's going to be slow. I'll talk a little bit about the Moving Forward Coalition group we formed after releasing the National Academies Report. We don't want this 600-plus page report to gather dust on a shelf somewhere. We want these recommendations put into action. So there are seven working groups around the seven large goals outlined in the report. I'm a co-chair of the payment and financing group and we're trying to do some innovative things with housing, working with Housing and Urban Development (HUD).
It's exciting to see the number of folks who have come together from different stakeholder perspectives. We have providers, advocates, ombudsmen, and regulators coming together to try to make change. The current model is not working great for anyone, so everyone wants to pitch in and change things. It's incredibly exciting to see the amount of effort.