The November 18th, 2014, Lab seminar featured two presentations, the first which was presented by Prachi Sanghavi, who is completing her PhD in Health Policy at Harvard University, and the second which was presented by Wallace Roberts, an investigative journalist and community organizer who is currently an Edmond J. Safra Network Fellow. Prachi Sanghavi’s talk centered on her research investigating the economies of influence that have prevented pre-hospital care from being rationalized in better ways, and ways in which the quality and efficiency of pre-hospital care in the United States can be improved. Wallace Robert’s talk focused on his investigation of institutional corruption in end of life care in the U.S., particularly in nursing homes. The overarching theme of the Lab seminar concerned institutional corruption in the provision of medical care in the United States.
Sanghavi opened the Lab seminar with a short presentation based on her current research investigating competing strategies of pre-hospital care in the U.S. In particular, Sanghavi’s research investigates the outcomes of two different types of pre-hospital schemes in the U.S.: Advanced Life Support treatment and Basic Life Support treatment. In short, Advanced Life Support (ALS) refers to ambulance and paramedic systems that remain on the scene longer in order to stabilize patients, while Basic Life Support (BLS) refers to ambulance and EMT systems that apply only basic life support functions in order to get the patient to the hospital as quickly as possible. The reason this is important is not only because each respective system yields different outcomes, but also because the policy implications of these competing strategies drive how the EMS infrastructure in the U.S. is developed. Currently, the U.S. is predominately an ALS country where 65% of Medicare beneficiaries get ALS, and in acute medical cases, such as a stroke or cardiac arrest, this statistic increases to 86%. This is problematic not only because there is little evidence to suggest that ALS is the superior pre-hospital care strategy, but also because a number of international studies consistently demonstrate that outcomes are the same or worse when ALS is chosen. Indeed, for developing countries, the World Health Organization (WHO) recommends not implementing ALS in the context of trauma. So why is ALS less efficient than BLS care? Sanghavi explained that usually the time it takes to administer ALS isn’t worth it, and that some of the interventions performed by ALS paramedics should not be delivered in the field because of certain quality issues with these interventions, such as intubations.
At this point in the seminar, Sanghavi gave a brief overview of her work comparing the effects of Advanced and Basic life support on survival, neurological performance, and spending outcomes in cases of acute out-of-the-hospital medical emergencies, such as cardiac arrests, strokes, trauma, heart attacks, and respiratory failure. By matching the ambulance Medicare claims of beneficiaries in non-rural areas, with corresponding hospital claims for patients once they were at the hospital, Sanghavi has been able to analyze the survival benefits for patients with acute medical conditions who received ALS care. Sanghavi’s research shows significant positive percentage points in survival rates for those who receive BLS rather than ALS, so it’s clear we should be emphasizing the principles of BLS in the U.S. So what can be done to change the predominately ALS system in the U.S.? Sanghavi suggested that we could change Medicare payment policies so that Medicare doesn’t cover ALS as much, which may drive down ALS. We might also think about changing professional organization guidelines with the American Heart Association, American Stroke Association, and finally, we could launch a public education campaign.
So what is the institutional corruption bent? Sanghavi explained that she believes that there are internal and external influences at work here. To begin with, in the U.S. we have an obsession with high-tech care, which invites the use of ALS equipped ambulances and instruments. Further, over the past 20-30 years the EMS industry has professionalized, which has thus created hierarchy, training, and certain payment structures. This, coupled with Medicare rules that condone and sometimes encourage ambulance companies to bill for more expensive services than needed, contributes to the predominance of ALS. Moreover, in the past 50 years or so fires have steadily decreased, yet the fire department business has grown. The reason for this is that fire departments have taken on this EMS business to keep themselves going.
At this point in the Lab Seminar, Wallace Roberts began his presentation based on his Network Fellowship project, which attempts to show how the nursing home industry is being corrupted by sociological and political factors. Roberts explained the problem in simple terms: in short, thousands of nursing home patients suffer serious abuse and neglect each year; beatings are not uncommon, and hundreds, maybe thousands are dying premature deaths. It’s hard to establish a solid figure; however, because the federal agency that shares some oversight of these facilities along with states, the Centers for Medicare and Medicaid Services (CMS), does not keep track of such figures. However, the Miami Herald did perform an investigation about nursing home deaths in Florida a couple years ago looking at deaths in nursing homes over a 7-year span, and counted 250 deaths.
So what is the reason for this problem? Owners of nursing homes refuse to hire sufficient amounts of staff, and CMS allows for lax regulation of care practices. The average fine for violations is $12,000, which Roberts called “peanuts” if average revenue per nursing home in the U.S. is $8 million per year. Moving on, Roberts explained that increased oversight would be particularly beneficial to nursing home care in the administration antipsychotics to patients with Dementia. According to the FDA, patients with Dementia should not be administered antipsychotics due to the increased risk of death; however, this practice is commonplace in nursing homes throughout the U.S., as it is used to sedate troublesome patients. What’s more, Roberts explained there is also lax oversight when it comes to nursing homes that are placed on CMS’s “Special Focus Facilities” list, a list that identifies nursing homes with health and safety violations. Some nursing homes have been on this list for years. Even more disturbing, In 2007 and 2008 CMS mandated that nursing homes must equip their facilities with automatic sprinkler systems within 5 years; however, after that initial time period ran out, there were still 700 homes without these systems.
Part of the problem of the lack of oversight is actually that both states and the federal government regulate nursing homes. States license nursing homes, but CMS writes the regulations, certifies nursing homes to get Medicare and Medicaid money, and contracts with states to perform inspections and investigate the complaints. This leaves a lot of room for potential conflict. Further, with the Centers for Medicare and Medicaid Services having five regional offices, there is a greater likelihood for missed communication. Most importantly, however, is the scheme of duel enforcement between states and the federal government, which allows for nursing home lobbyists to press for lax enforcement at the state level. This is quite effective, as there is practically a nursing home in every state assemblyman’s district, and lobbyists therefore approach members of state legislatures asking for lax enforcement.
Closing his portion of the Lab presentation, Roberts explained how he initially became interested in investigating end of life care, and discussed the troubling incentive structure of viewing nursing homes as real estate investments, which too often corrupts or compromises their mission to deliver quality care. Roberts first became interested in this problem when he was working for Common Cause Vermont and one of his jobs was to construct a database of campaign contributions in the 2010 election, as the state didn’t have the capabilities or the will to do it. In doing so, he began to notice suspicious campaign donations from Golden Gate National Senior Living Center (GCNSC) to the incumbent Attorney General. GCNSC is one of the third largest nursing home chains in the country, which is owned by a private equity company, Fillmore Capital Partners. At the time, Vermont was one of the states where GCNSC was facing a lawsuit. After more research, Roberts discovered that six of the top ten nursing home chains were either owned by Private equity companies or REITs. He went on to talk about how the money in nursing home business is valued in terms of buying and selling nursing homes as real estate, and how this creates an incentive structure that rewards cost cutting measures rather than quality care.
- Summary composed by Joseph Hollow