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--> Appendix C Separate Statement and Responses Appendix C consists of two parts. Part 1 is a separate statement prepared by committee member James Blumstein. Part 2 is a response to that statement by other committee members. Part 1: Separate Statement From The Report Of The Committee James F. Blumstein Overall, this report reflects a reasonable statement about the issues the Committee was charged with investigating. Although I and probably most committee members disagree with certain statements or would state certain items in different ways, in general we have agreed to compromise in order to reach consensus. Nevertheless, I feel constrained to comment separately on what was probably the single most contentious issue confronted by the committee, recommendation 6-1, which recommends 24-hour registered nurse (RN) coverage for all nursing homes by the year 2000 along with the appropriation of sufficient funds to pay for this enhanced level of service. Two provisions—one contained in the Recommendation and the other in the text explaining the Recommendation—warrant highlighting. First, the term ''coverage" is used in recommendation 6-1. This suggests that full-time staffing should not be mandated. Presumably, the requirement could be satisfied by having RN services available on an "on-call" basis. This procedure is followed in traditional medical circumstances, and would allow for efficiencies by allowing
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--> RN services to be "on-call" for more than a single facility. For larger facilities, a staff RN might be appropriate and feasible on a 24-hour basis (this staffing is already in existence for many nursing homes, either because it is required or on grounds of good practice), but for smaller facilities and in less wealthy Medicaid jurisdictions, the more economical sharing arrangement might suffice. This recognizes that some increments of quality might have to be traded off in the name of reasonable expenditure constraints and alternative claims on Medicaid and Medicare dollars. Second, the 24-hour RN coverage mandate contained in recommendation 6-1 is subject to appropriate waiver. No criteria are specified in this waiver provision. Some committee members believed that the waiver should apply only when RN personnel are unavailable; others felt that waivers are appropriate when economic considerations make the requirement unwise in terms of cost–benefit analysis, especially in light of the opportunity costs associated with the 24-hour RN requirement in some foreseeable situations. Further, the "unavailability" standard inherently has an economic dimension, since the unavailability problem would be reduced or eliminated if money were no object and the price were, therefore, right. Despite the flexibility implied by the term "coverage," I reluctantly state my disagreement with recommendation 6-1 because it is not based on careful consideration of evidence and a balancing of competing claims on public resources; rather, the Recommendation was reached without consideration of alternative uses of public funds or consequences from this proposed new mandate. My substantive concerns have two components. First, the committee made this recommendation without any hard evidence about the costs involved or about the value of the benefit to be derived. Second, inadequate consideration was given to the desirability of allowing states freedom to set priorities and allocate public funds. (a) There were few data presented or discussed regarding the cost of recommendation 6-1. There was an estimate provided by the nursing home industry that each additional hour of mandated nursing service would result in an increased nursing home cost for Medicare and Medicaid of $3.4 billion per year. One cannot just multiply $3.4 billion per year by the additional 16 hours proposed in recommendation 6-1 to calculate the incremental cost of the proposal above existing expenditures. Many nursing facilities satisfy the proposed standard, but that number was not presented to the committee during its deliberations regarding recommendation 6-1. Further, the Recommendation does not necessarily call for additional hours of nursing service but only for upgrading the quality of nursing service. Thus, the industry's estimate does not provide an appropriate measure of the incremental cost of the committee's proposal. The problem is that the committee had no evidence to determine how many facilities would be affected and to what extent. Estimation of cost in such circumstances is
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--> back-of-the-envelope guesswork at best. In response to this criticism, a subsequently developed ballpark estimate has been included in the report, but the committee had no opportunity to discuss the estimate or consider it in terms of putative benefits or alternative expenditures. In addition, although the committee could assert that staffing levels in general have a positive correlation with quality of care in nursing homes, it could not pin down those benefits in causal terms with any precision. Just what precisely is the benefit that will come from the proposed Recommendation? This is hard to identify or measure with specificity. Further, the committee made no effort—because the literature would not sustain such an effort—to evaluate the benefits that might accrue. To support recommendation 6-1, it is not enough to recite a relationship between overall staffing intensity and aggregate quality outcomes. More precision is needed, and some mechanism for evaluating the purported benefits is necessary in order to conduct sensible policy discussions and to establish priorities for public spending responsibly. Why 24-hour coverage and not 16 hours? Why only one RN in even larger facilities? With this gap in data, the Recommendation takes on the air not of professional or scientific judgment but of politics. Implicitly, the committee acknowledges this. See Chapter 6, page 167: ("The small staffing increases under OBRA 87 required substantial new resources. These staffing increases were apparently based on the amount legislators and industry leaders considered to be politically and fiscally feasible, …"), and on that score, an IOM committee has no special wisdom. (b) Recommendation 6-1 is another proposed federal mandate at a time when these mandates are being called into question. The committee was conscious of this concern and, responsibly, included a funding element to the Recommendation. Nevertheless, at least for Medicaid, state participation in financing is currently a requirement; thus, this is the kind of mandate that Congress has recently disavowed. Beyond a basic requirement, which is satisfied by current rules, local priorities should generally be respected. This is particularly true when the costs are unknown and the nature and value of the benefits are also uncertain. Since Medicaid accounts for such a large proportion of nursing home services, public dollars are at issue, and in the absence of some overriding federal interest (such as assurance of civil rights), local political tastes should prevail. States may differ politically with respect to evaluating alternative claims on public resources. This could mean that some states would prioritize other needs in health care, or it could mean that states would elect non-health care expenditures such as schools or prisons as higher spending priorities. Beyond the basic requirement, states should be allowed to choose how to allocate public dollars on the basis of their own political priorities and on the basis of their self-perceived financial capacity.
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--> Part 2: Committee Members' Responses To The Separate Statement Of James F. Blumstein We are compelled to respond to the statements of Mr. Blumstein because we disagree with the position that he has stated in his response to the report, especially the statement that the recommendations were made without careful consideration of the evidence. On the contrary, these decisions were made carefully with great deliberation and with consideration of the financial costs. Recommendation 6–1, as stated by the committee, was that every nursing facility should be required to have direct care by at least one registered nurse on a 24-hour-a-day basis as a minimum mandate. This recommendation to strengthen current standards grew out of strong research findings that facilities with more registered nurses have a higher quality of resident outcomes. The data from nursing facilities showed that some had inadequate numbers of registered nurses, which we considered showed the need for stronger minimum standards. Based on the research findings, some members of the committee supported even stronger minimum mandated staffing levels for registered nurses and other nursing personnel, including nursing assistants. The primary reason that many experts have been unwilling to support even higher staffing standards is the high cost to the Medicaid program, which pays for a majority of nursing facility days of care in the United States. Thus, the concern is strictly one of political and economic feasibility—not a dispute among nursing professionals over the need for more nursing personnel. Not only are high professional standards for nursing facility care advocated by professionals who are knowledgeable about the needs of residents, but such standards have been demonstrated to make a difference in terms of resident outcomes. Research conducted by economists, sociologists, nurses, and other health services researchers has been carefully detailed and documented in this report, and it is the basis of the recommendations made. The research indicates that if more nursing professionals were added, the outcomes in nursing facilities could be substantially improved. Although some nursing professionals on this committee argued that the needs were much greater than the modest recommendation made by the committee, even our views were tempered by the poor national economic climate and the perceived financial crisis in the Medicare and Medicaid programs. If the recommendations were based solely on the need for nursing care and professional standards, the recommended standards could have been substantially greater. The committee debated the current waiver provisions for facilities that cannot meet the staffing standards. The general perspective was that facilities should not be granted waivers and should make every possible effort to meet the minimum federal standards. The current availability of registered nurses in the market argues against the need for waivers, even in rural areas. The committee, however, did not ask for the repeal of these waivers because there may be some
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--> extenuating circumstances that it could not foresee. The committee did not propose the exact criteria for waivers specifically because such criterion development was beyond both the scope and the expertise of its members. The committee did consider the costs of recommendation 6–1 and found that it would be approximately $338 million dollars. The committee has specific data on the cost difference between a licensed practical nurse (LPN) and an RN salary from the Department of Labor, which show that the differential was about $4 per hour in 1994. If every nursing home in the United States needed to convert one LPN to one RN on the evening and night shifts (which is an overestimate since many facilities already meet the minimum standard), the cost of the recommendation would be approximately $338 million. This seemed a rather small investment in a $74-billion-dollar industry in 1994 (less than 1 percent of total expenditures) to improve the quality of care for the most vulnerable individuals in our society. Mr. Blumstein raises the issue that the cost of each additional hour of nursing service is estimated to be $3.4 billion. This cost is not applicable to the recommendation, because facilities already have at a minimum at least one licensed practical nurse on the evening and night shifts, as required under current law. Since the recommendation is not adding new nursing hours but rather upgrading the educational requirements for nursing personnel already present in facilities, Mr. Blumstein's estimates are not correct. Those who dislike regulations should understand that adding more nursing care could save on regulatory efforts in the long run. It should reduce the high admission rates from the nursing home to hospitals and lower the total costs of hospital care under both the Medicare and Medicaid programs. In the long run, increasing professional nurse staffing in nursing homes could result in substantial savings to both the Medicaid and the Medicare budgets. Current research data on nursing facilities, like other health services research data, do not have the precision that we would like. However, although we may lament that the real world of nursing facility and hospital care is too complex to calculate the exact cost–benefit in adopting improved staffing standards, we must make our best judgments based on the information available. This brings us to the recommendations that were made for a small increase in minimum staffing standards and continued research to improve the quality of care delivery in the most efficient way. Dyanne Affonso Erika Froelicher Linda Hawes Clever Charlene A. Harrington Joyce Clifford Sue Longhenry Edward Connors Elliott C. Roberts, Sr. Carolyne K. Davis
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--> Personal Response to the Separate Statement of James F. Blumstein First, I find Mr. Blumstein's statement extremely difficult to follow; therefore, I will not try to respond to all aspects of it. However, I personally object to the inclusiveness of the language in the second sentence of this statement that says "… most all committee members disagree with certain statements. …" It is my belief that the committee worked very hard to have consensus in this important report. Any compromises I may have made related to what I might have desired to add to the report, not with what is in the report. I do not believe that a dissenting statement of one member of the committee should suggest that there was disagreement by other members as well, and I strongly urge that this statement be limited to the author and not include any reference to the opinions of other committee members. It also concerns me that the statement suggests that recommendation 6-1 was made without "careful consideration of evidence. …" This recommendation was not made lightly, and it was not made without recognition of the financial burden that it might incur. Mr. Blumstein suggests that registered nurses could be on-call rather than on the premises of a facility. This suggestion is totally unacceptable as a means of providing minimum professional protection and care for very ill and disabled individuals, who frequently have complex nursing and medical care needs, as well as medical emergencies, that require immediate skilled nursing attention. I voted for this recommendation because it was the right thing to do in light of the increasing acuity of care needs in nursing homes, the knowledge that we do have about the relationship of quality and staffing, and my own 30 years of experience in developing, implementing, and evaluating nurse staffing in hospitals. Joyce C. Clifford, RN, MSN, FAAN Vice President, Nursing and Nurse-in-Chief Beth Israel Hospital Boston, MA 02215
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