How Not to Improve Nursing Homes

Assisted Living cottages on Visingsö Island in Sweden

While we were all distracted last week by the President’s racist and anti-immigrant statements, the administration took two steps that will weaken oversight of nursing homes.  The first change addresses a rule that prevents nursing homes from requiring mandatory arbitration.  This change will allow them to include mandatory pre-dispute arbitration clauses in their contracts with residents.  In other words, residents or their representatives will not be able to go to court to address potentially harmful circumstances such as abuse or neglect.  The second step is a proposal that will weaken federal nursing home standards around issues such as infection control and prevention, dementia care, and basic issues related to quality of care.  

It is hard to imagine an industry in as much need of reasonable regulation as nursing homes. There are some high quality facilities, but in the typical nursing home care rarely rises above mediocre. Regulations alone won’t correct the problems in nursing homes, but loosening them is going to leave more loopholes for nursing homes to cut corners and sacrifice the well-being of residents in order to squeeze out more profits.

These changes raise a larger issue—whether health care should be “for profit.”  The long-term care settings that we believe provide high quality care are usually (but not always) non-profits.  The care is often innovative, and staff are always looking for new ways to improve care. For these facilities, the well-being of patients is more important than maximizing profits.  By contrast, the for-profit places we have visited over the years usually just go through the motions.   The care is not inspired or innovative.  Research has confirmed differences in quality of care between non-profit and for profit facilities.  When the goal is to increase profits, it is easy to rationalize making cuts in quality of care.  

Several years ago, Judy was consulting at a large retirement community that provided different levels of care from independent apartments to a nursing home.  A selling point was the quality of the food.  The facility had its own chef who prepared nutritious and good tasting meals.  Good food is one of the things that nursing home and assisted living residents can still enjoy.  The owner ran into money problems—not related to the balance of operating expenses and revenue, but as the result of a divorce settlement.  To save money, he fired the chef and brought in a meal supply company that provided pre-cooked food that was high in salt, low in flavor and where fresh fruit and vegetables were rarely seen.  The owner had started out doing the right thing, but to increase profits he readily cut costs.  The facility also adopted an approach of keeping the more expensive beds in nursing homes filled.  When there was a vacancy, staff would select someone in assisted living to fill the bed, whether or not that level of care was needed. This maximized profit.  So much for the promise to residents that they would receive support to remain as independent as possible.

The appropriateness of the profit motive throughout the health care field generally needs to be re-examined.  When there is an emphasis on profit, people will be tempted to cut corners.  That’s the case whether it is medicine, pharmaceuticals, psychologists, or other health care providers.  Of course, non-profits can pursue income over quality care, too. In Pittsburgh, medical care and insurance are dominated by two large non-profits, who have been at war with each other for some time.  They are run like corporations, with skyscrapers that dominate the downtown skyline and highly paid executives.  Reform of what it means to be a “non-profit” needs to be considered, too.

But when it comes to choosing a nursing home, a non-profit facility may be the best bet. 

For more information about the changes in nursing home rules and standards, visit the website for The Long Term Care Community Coalition at www.nursinghome411.org.  You can also learn where you can write to comment on the proposed rules to lower nursing home standards.