Dr. David Grabowski, professor of health care policy at Harvard Medical School, spoke at the University of Massachusetts on the current challenges and potential solutions of nursing home care in the United States.

Grabowski, an internationally recognized health economist and health services researcher, specializing in aging, long-term care and policy analysis, gave his presentation on Thursday, Feb. 8, in the Commonwealth Honors College.

As of 2014, nearly 1.5 million people live in 15,600 nursing homes across the U.S.—only a couple thousand more than the number of Starbucks stores in the country., noted Grabowski. However, despite the large numbers, quality has been a longstanding issue for nursing homes. Grabowski argued that the issue doesn’t stem from individual homes or their staff, but from the entire system.

The nursing home sector is heavily regulated, second highest in the U.S., right under nuclear power, noted Grabowski, with prices set by Medicaid and Medicare administrators. Other perceived issues include considerable supply constraints, uninformed consumers and a “tremendously” fragmented system.

“The fragmented U.S. system is perfectly designed to achieve higher costs and worse health outcomes,” he said, posing the question of how society can ensure parents and grandparents will receive high-quality, person-centered care.

Grabowski’s research at Harvard explores what nursing homes would look like if they adopted market-based approaches to their business. Today, the standard economic model for the open market means prices are set in the marketplace, entry and exit of firms, well-informed consumers and a coordinated system of care.

There are three models Grabowski attempted to implement in order to study how these ideas operated in the nursing home market: pay-for-performance, report cards and integrated models for care.

Pay-for-performance profits individual nursing homes for providing quality care to patients, giving staff an incentive. Ideally, a well-designed pay-for-performance model would offer meaningful and immediate rewards, educate and guide providers on best practices and minimize unintended consequences. In a trial demonstration, 171 nursing homes across three states showed no profit after the third year with basic pay-for-performance guidelines, Grabowski explained. Performance-Based Incentives (PIPP) is a newer, different kind of pay-for-performance.

“This isn’t a pool of money that nursing homes can win by performing better, but rather, they get by proposing an improvement program to the state,” he said.

According to Grabowski, in a trial in Minnesota, PIPP fulfilled all requirements in a quality pay-for-performance. This year, programs range from simply aiming to improve employee engagement, while others attempt to reduce substance abuse dependency in mentally ill patients.

The next market-based approach, report cards, are based on the premise that a lack of info can lead to suboptimal outcomes for care.

“Many nursing homes’ residences lack the ability to ascertain and ultimately monitor quality of care. This could be because of high rates of cognitive impairment because they don’t have family, and obviously, something’s changed… this is done very quickly,” Grabowski said.

Associate dean of research at the UMass College of Nursing Annette Wysocki pointed out that “the system as a whole is not designed for informed, timely decisions.” Usually, patients are brought in after a serious incident, like a fall, stroke or another event that requires consistent nurse care as soon as possible.

An impactful report card is well utilized and easily interpreted by stakeholders, which reduces search costs and avoids potential unintended consequences, according to Grabowski. Medicare’s Nursing Home Compare has been attempting to do just that since the 90s. The service provides information on the quality of resident care and staffing for more than 15,000 nursing homes around the country.

Today, it offers more tools than ever, including nurse staffing data and the Nursing Home Quality Initiative. Prior to 2008, the website wasn’t widely used due to the dense statistics of information—that was until they introduced their five-star rating system. According to Grabowski, patients and families alike are using it much more often, but nursing homes dislike the site. They don’t think it’s a good, fair measure of quality.

Grabowski argued that more individual care is needed across the board. Accommodations need to be made for every patient, long-term or post-acute.

Ning Zhang, assistant professor at UMass’ School of Public Health and Health Sciences, said, “U.S. regulations require hospitals and emergency offices must have the ability to provide good care to obese patients…But there’s no such regulations in nursing homes.”

Nate Procter can be reached at [email protected].