Veterans Healthcare Policy Institute
VA Nursing Homes
June 20, 2018
Beyond Inflammatory Headlines & Into the Data
On June 17th, the Boston Globe and USA Today released stories that seriously questioned the quality of care in Veterans Health Administration nursing homes. The inflammatory title “Secret VA nursing-home ratings hid poor quality are from the public,” has become a staple of much media coverage of the VA. In this case, reporters Andrea Estes and Donovan Slack claimed that 60 of 133 VA nursing homes received the lowest ratings.
In headlines and quotes from veterans’ families, the story says VA nursing homes “break their spirit.”
“Anybody that deals with the VA, I feel sorry for them,” one veteran’s wife says, while the son of another insists that veterans would all but much better cared for in private sector facilities.
The take-home message is that outsourcing care to the private sector would be better for veterans, in this case the kind of for-profit nursing homes that dominate the nursing home industry. It’s a narrative that has become typical of articles that have appeared in USA Today and in much of the mainstream media.
Sadly, this article, like so much other media coverage of the VA, contains serious omissions, fails to mention critical quality measures that are used to judge the quality of nursing home care, and neglects to inform the reader about the often appalling quality of care in the nation’s private sector nursing homes.
Bad, compared to what?
Although the article claims that 60 VA nursing homes received a one star rating, the VA data shows that only 11, or eight percent of VA nursing homes, received one star ratings.
This compares favorably to private sector nursing homes. When rated by the Centers for Medicare and Medicaid Services, 12.6 percent of private sector nursing homes receive one star ratings.
The summary scores of VA nursing homes show 29 percent with a 4 star and 26 percent with a 5 star rating. Private homes report 22 percent with a 4 star and 29 percent with a 5 star rating.
The article fails to help the reader understand how experts judge the overall quality of nursing homes. There is an overall rating, a rating based on the survey deficiencies, a rating on staffing, and a rating on resident quality measures. The average VA nursing home has an overall rating of 3.4, which is better than the national average and they have a 3.0 rating on deficiencies, which is the national average.
The article does not consider the single most important measure on which experts judge nursing home quality – nurse staffing.
The VA has an almost a perfect score on high nurse staffing, 4.95 percent.
Nurse staffing includes the Registered Nurses (RNs), licensed vocational nurses (LVNs) and certified nursing assistants. Adequate staffing levels are essential to help residents with bathing, dressing, going to the toilet, eating, walking as well as providing medications, and treatments.
The VA has traditionally had better staffing than private sector nursing homes and less turnover and more stable staff to care for residents. Indeed, private sector nursing homes score far worse on staffing and deficiencies. Less than 80 percent of private sector nursing homes have adequate RN staffing and 20 percent cause harm and jeopardy to residents each year.
Instead of including nurse staffing and deficiencies, the USA Today and The Boston Globe have centered their stories on the least reliable measures by which one can judge nursing home quality.
These measures on resident quality, whether in the VA or private sector are self-reported. Private sector nursing homes have a strong incentive to report better outcomes, which are used to judge their quality.
While they may have the Centers for Medicare and Medicaid Services stamp of approval, none of the quality measures in nursing are audited to verify the accuracy of these measures. An independent study by Abt Associates, for example, found a “high level of variation in SNF (skilled nursing facilities) across L&C geographic areas.”
Because the VA has used the resident quality measures for the purposes of internal improvements, the VA may actually have the opposite incentive to more accurately report its resident quality measures.
Thus, the discrepancy between VA nursing homes and those in the private sector may actually have to do with the fact that the VA may be more accurately reporting any problems and work toward quality improvement.
The issue of resident quality measures as it appears in these articles is also problematic for another reason.
The article implies that the quality measures used by the Centers for Medicare and Medicaid Services (CMS) are comparing all private nursing homes in the US to those in the VA. In fact, the CMS data linked to the article does not compare the VA to all private nursing homes, but only to a small subset of private nursing homes with which the VA contracts to provide services to eligible veterans.
There are stringent requirements that such private nursing homes must meet in order to contract with the VA. The VA does not contract with nursing homes whose survey scores’ scope and severity indicate widespread or actual harm to residents.
The article is thus misleading because it fails to clearly explain that the VA is not being compared to all nursing homes but only to a subset whose scores are higher.
The article also minimizes data showing overall improvement in VA nursing homes: 45 percent of VA nursing homes have improved and only one, which had a four star rating, has declined.
Lower scores on some resident quality measures may also be related to the serious challenges of caring for the type of residents/patients who fill VA hospitals and nursing homes.
The VA patient population is predominantly male and younger than those in private sector nursing homes. To be eligible for care, the 46,000 veterans who are currently in either in VA nursing homes or nursing homes with which the VA contracts are required to have 70 percent — or greater — service connected disabilities.
This means that they have more serious physical and mental problems than the older female patients who fill most private sector nursing homes.
The VA Patient Population
Many more veterans than civilian sector nursing home patients suffer from chronic pain conditions and traumatic injuries.
Some VA patients have spinal cord injuries, which means they may use more catheters, and have more pain and are at greater risk for bedsores.
Because most VA nursing homes patients are men, they may have prostate problems causing obstructions that require the use of a catheter. Some Vietnam veterans in VA nursing homes have Agent Orange related diabetes, which can lead to what is known as a neurogenic bladder (i.e. loss of control of the bladder) which requires a urinary catheter.
In general, veterans have many more problems with chronic pain than most of the civilian population – and certainly most of the female patients that populate the nation’s nursing homes. Some VA nursing homes have chronically ventilated patients, many of whom would be catheterized.
VHA patients also have more mental health problems than the average nursing home patient and may take more psychiatric medications. Studies have shown that the kind of mental health problems from which veterans suffer are also associated with greater perception of pain.
Vietnam veterans with PTSD also have increased disability. VHA patients are, on average, sicker, poorer, and more complex than most private sector patients.
Private sector nursing homes care for far less complex patients because most facilities rigorously screen applicants before accepting them. Many nursing homes refuse to take complex cases that may have bad outcomes that will pull down their scores. Some even evict complex patients.
Thus a patient with serious and physical emotional problems may very well find it extremely difficult to get a nursing home bed even if they can pay for it privately. Or they may face eviction if they become too complex.
Even the nursing homes with whom the VA contracts may refuse complex veterans or patients with behavioral problems due to dementia and PTSD.
The ability to pay for nursing home care is yet another screening mechanism. If someone can’t afford to pay privately after their Medicare benefit is exhausted then many nursing homes refuse to accept them as residents.
Although many nursing homes will take Medicaid patients, they screen them heavily. Many studies that show that minorities and individuals on Medicaid — precisely the kind of patient that fills VA facilities — are sent to poor quality nursing homes.
The VA, on the other hand, must take all patients that meet the eligibility criteria and are not able to screen and refuse those who would have more complex mental and/or physical problems.
“If we are to assure that care to veterans is of the highest quality, better, more accurate and nuanced reporting about veterans’ health care is essential.”
It is clear that the VA should be making its reports public as they are currently doing. The VA should also help to educate veterans about how to read nursing home report cards on quality so that they can understand the difference, for example, between resident quality measures, and staffing and deficiency measures.
The VA should be, as it says it is doing, trying to improve care in nursing homes and elsewhere.
The bias of the Boston Globe and USA Today reporters toward private sector nursing homes ignores the fact that most private sector homes are unlikely to accept the kind of complex patients the VA cares for — more of whom will fill nursing homes in the future.
It’s hard to imagine for profit nursing homes welcoming the kind of homeless veterans or those with amputations, coupled with traumatic brain injuries and PTSD that our current conflicts have produced.
If we are to assure that care to veterans is of the highest quality, better, more accurate and nuanced reporting about veterans’ health care is essential. The VA should be commended for its overall high quality of care and high staffing levels in its nursing homes.
Suzanne Gordon - VHPI Senior Policy Analyst
Charlene Harrington - VHPI Advisory Board Member, Professor Emeritus at the University of California San Francisco (UCSF) School of Nursing