The Department of Easy Medicare Answers is Closed for Repair

As you get older, the odds are considerable, and rising with age, that you will spend time in a nursing home. The most common pathway is that you will be admitted to a hospital and, once your condition has improved, sent for further recovery to an SNF, or skilled nursing facility.

These visits can be significant events in determining the quality and quantity of your remaining years. Especially given the horrific front-line tales of how nursing home patients struggled with COVID, the process of finding a good home is more important than ever.

(Medicare changes in the Deficit Reduction Act are a big, big deal. Links to details are on my home page.)

I am always on the lookout for solid advice to help people make informed health care choices, so I was really happy to see a fascinating study about the quality of care that people receive in nursing homes.

The three authors sifted through detailed Medicare records on people who spent time in SNFs between 2011 and 2016. In theory, it would be great if such research could be more current but, as today’s headline suggests, timeliness and detailed health research seldom coexist.

“Complete” is also a word you’re unlikely to see in competent research. This study, for example, looked at 6.2 six million Medicare patient stays at nearly 14,000 nursing homes across the country. It looked only at a patient’s first SNF stay, which was the main factor in weeding out another 4.5 million stays at more than 2,000 additional homes.

The results are still eye-opening. Using an exhaustive list of health-related outcomes, the study created a health index for each patient and was then able to assign how well each home performed – they call it value added -- based on how much each patient’s health index improved between the time they were assessed when admitted and after a later assessment.

They found enormous differences between homes. Nationally, homes in the 90th percentile of value added were able to send people home more than six days earlier than homes in the 10th percentile of value. This reflects savings in the costs of SNF stays but, more importantly to me, measurable health benefits.

“The most important variable for predicting discharge to the community is pain intensity,” the authors reported. “Other important variables include mood score, needing help with toileting, and needing help with locomotion.”

National findings are important to policymakers but less so to consumers, who base their SNF choices on nearby homes. Here, the study also hit pay dirt, finding that the local-market differences in care between the 90th percentile and 10th percentile homes exceeded five and a half days.

In other words, high-quality homes are nearby. We just have to find them.

Fortunately, the Centers for Medicare & Medicare services (CMS) produces extensive measures of nursing home quality and puts them online as star rating in its Nursing Home Compare tool. Unfortunately, the authors compared their ratings with this tool and found “our estimates of nursing homes’ value added are only weakly correlated with their CMS star rating (correlation of 0.12).”

In other words, either their research is misleading, which I doubt, or the government’s primary tool to help people select a nursing home produces wrong and misleading recommendations. Others have found similar shortcomings with the CMS tool, too, thus providing another rationale for today’s headline.

The further limitation of their research, the authors agree, is that it is based on pre-COVID data that is now six years old.

What to do? I wrote a book about this, or at least a small part of a book.  In it, I spoke with Mike Baker, a health insurance company executive who oversees consumer call centers. Here’s how he shopped for nursing home for his dad:

“My father passed away a couple of years ago, and we were at a moment where he was coming out of a hospital and going into a SNF [skilled nursing facility] and that skilled nursing spot was in Tucson, Arizona. At the time, there were four or five choices, so we had a little bit of time to do a little research. We asked the physician that he was accustomed to seeing. But none of us had ever been in that position before, no one had asked folks at the hospital for a recommendation, and there were wild variations among us on our perspectives on what was a good facility and what was a bad facility.

“And so I kind of performed my own assessment the same way that I do when I walk into a call center. I’ve been running call centers my entire professional life, and you can tell in 10 minutes how an operation runs. And I show up for a site visit and I walk into a bathroom. How clean are the bathrooms? Because that stuff matters in an operation. You walk by the bulletin boards. And is it May or June but there’s awards up from March on the wall? Are there, you know, TVs in the break room, but the cable’s not working? If there are little details that are missed, the big details are going be missed.

“So I called the higher recommended nursing facilities. I called the front desk at 8 o’clock at night to see how long it took somebody to answer. I asked for a nurse on duty and saw how long it took to get someone’s attention. I drove by and walked into a couple of places. Could I get in and walk in? Was the desk attended at 9 o’clock and what was that environment like? And while that is certainly not a parallel for what the clinical experience is going to be, it gives you an indication, I think, to the kind of attention that’s being put on the human beings that are a customer of that facility.”

(Additional content for paying subscribers: Useful Nursing Home Staffing Details, Updates on Nursing Home Safety, Hospital Pricing Rules, and The Choice You Need to Get Right: COVID Era Nursing Home Selection.)

Philip Moeller is the principal author of the Get What’s Yours series of books about Social Security, Medicare, and health care. @PhilMoeller