Why the survey system may never be fixed

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John O'Connor
John O'Connor

Lately, we've been hearing much about the need to improve the nursing home survey system. The outcry is hardly surprising, given that the New York Times recently exposed dubious Five Star grade-inflation practices.

In some ways, the solution here would appear to be simple. And yet, the survey system may always be somewhat broken. More on that in a moment. But first, a bit of background.

For those unfamiliar with the saga, the paper of record recently posted a front-page story that filleted the inspection process. In their efforts to maximize Five Star ratings, a number of facilities were turning in fictional staffing and quality indicator data.

It would appear that an unholy trinity of factors coalesced to gum up the works. The first flaw is a ratings system built with perverse incentives. Calling on operators to self-report staffing and quality numbers — and then using those numbers to determine a grade? Really?

The second is laggard technology: For while the Affordable Care Act requires that the Centers for Medicare & Medicaid Services use payroll data to verify staffing levels, an actual tool for doing so does not yet exist.

The third is simple negligence: While CMS should have been spot checking numbers that operators submitted, there is scant evidence to indicate such follow-up occurred.

Given these realities, we should not be wondering why cheating occurred. Rather, we should be amazed it hasn't been more rampant.

So what's to be done? The long-term fix is to completely remove self-reporting from the process. But until that happens, CMS must make a better effort to ensure reported staffing numbers are accurate. The feds also need to spot audit more aggressively.

Then the survey problems will be fixed, right? Not so fast.

As a child, I was a regular reader of Mad magazine. It's not what you'd call a highbrow publication, and I'm not especially proud of this habit. But one of its regular departments offered great insight into the dynamic that exists between regulators and fields that are regulated.

“Spy vs. Spy” is a wordless comic strip. It pits two spies who are always conniving to outwit each other. As soon as one spy creates a booby trap, the other returns the volley with an even more convoluted counter move. So what does this have to do with long-term care? This:

On its face, long-term care would seem to be one of the most altruistic endeavors on the planet. And in many ways, it is. Heroic caregiving efforts routinely play out every day at facilities across the nation.

Yet, and it pains me to say this, many operators appear far less interested in making a difference than in making a buck.

Not that the altruism vs. self-interest debate is limited to long-term care, or is even a new argument. For centuries, great thinkers have been trying to figure that one out. Philosophers such as Bernard Mandeville and Francis Hutcheson addressed this question head-on, and arrived at different conclusions. After giving the matter serious thought for a long time, I've come to this irrefutable conclusion about what makes people behave as they do: It depends.

It depends on the values of the person involved. It depends on incentives. It depends on the person's biochemistry. And it depends on other factors that may or may not be evident.

As no two people are exactly alike, we should hardly be surprised when they respond differently to similar scenarios.

When it comes to senior living, some operators will always put what's best for residents first and foremost. Others will not. That reality will always exist, regardless of how the rules are adjusted.

John O'Connor is McKnight's Editorial Director.

Daily Editors' Notes

McKnight's Daily Editors' Notes features commentary on the latest in long-term care news and issues. Entries are written by Editorial Director John O'Connor, Editor James M. Berklan, Senior Editor Elizabeth Newman and Staff Writer Emily Mongan.

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