Medicare/Medicaid and Quality Care for the Elderly

Because nursing homes receive Medicare and Medicaid funding, they are subject to stringent regulations issued by federal and state agencies, which seek to ensure that beneficiaries receive quality care. As part of the quality assurance process, the Office of Long Term Care Services, Assurance & Licensure Services, Division of the Department of Health Services, regularly inspects all nursing homes to make sure they meet federal and state standards. Inspections are generally conducted annually, but may occur anywhere from every 9 to 15 months. These inspections, commonly referred to as surveys, evaluate facilities on several measures, including quality of care, quality of life in the facility, the degree to which residents’ rights are observed, and whether the facility is hazard-free and meets cleanliness standards. Facilities found to be deficient in any of the areas assessed face a variety of sanctions, such as termination of Medicare monies. In addition, the survey results are made available to the public on Medicare’s Nursing Home Compare Website (www.medicare.gov/NHCompare), which is intended to help consumers shop for nursing facilities. 

The quality measures assessed are constantly evolving, with new ones published on the Centers for Medicare & Medicaid Services (CMS) Website (www.cms.gov) this past June. An article by Dr. Cefalu in this month’s issue of Annals of Long-Term Care (page 33) questions the clinical relevance and accuracy of these latest measures and recommends modifying them so that they provide a more accurate and fairer assessment of the quality of care in the nursing home setting. For example, one CMS quality measure is the number of long-stay residents who experience one or more falls with major injury. Long-term care residents are often prone to falling because of age-related changes, the presence of multiple comorbidities, and the use of numerous drugs to treat their various conditions. In addition, all these factors contribute to an increased risk for fracture when a fall occurs. Although many interventions may reduce the risk of falls and injury in nursing home patients, no one thus far has documented a clearly effective solution for this important problem. As a result, Dr. Cefalu suggests that CMS should instead assess how many residents had an adequate care plan in place to prevent a serious injury at the time a fall occurred. Other quality measures examined in the article include depressive symptoms, indwelling catheter use, urinary tract infections, weight loss, pain, and pressure ulcers.

In another article examining a Medicare/Medicaid quality care issue, “Improving the Care of ‘Dual Eligibles’—What’s Ahead” (page 26), Dr. Stefanacci discusses the difficulties in optimizing care for patients who qualify for both Medicare and Medicaid, a population commonly referred to as dual eligibles. As Dr. Stefanacci notes, this population generally has high care demands, yet faces considerable challenges in obtaining the care required because of confusing and uncoordinated payment systems. The article outlines several measures and programs that have been enacted to improve care for this population, such as special needs plans, the Money Follows the Person Rebalancing Demonstration Program, and the Affordable Care Act. Dr. Stefanacci notes that the improvements in care coordination of dual eligibles afforded by these measures and programs may open up new opportunities for geriatricians.

What do you think about CMS’s latest quality measures? Do they accurately reflect care in the nursing home? Let us know your thoughts by sending a letter to the editor to Christina Loguidice, editorial director, at cloguidice@hmpcommunications.com, or by voting in our monthly poll.

Thank you for reading!