The passage of the Social Security Act in 1935 marked a turning point in the history of aging in the United States, but it also created a new problem for the federal government: how to keep track of payroll information for the millions of workers who would now pay into the new pension insurance program and one day dip into the benefits they had earned.
The solution was the Social Security number, a nine-digit identifier unique to every American worker. When it was first developed, this was the only intended task of the SSN; in fact, from 1946 to 1972, every Social Security card carried the bold warning “FOR SOCIAL SECURITY PURPOSES – NOT FOR IDENTIFICATION PURPOSES”.
Of course, this warning was never taken seriously. Over the years, the humble SSN has become a de facto government identifier for a multitude of institutions, from banks and mortgage lenders to utility companies and homeowners. As a high school student in the mid-2000s, I was even told to put my name, date of birth, and SSN in the header of every page of my college essays to make sure it didn’t. there was no identity confusion.
The officials who developed SSN in the mid-1930s did not know they were creating solutions to a bigger problem than tracking government benefits. In a decentralized country like the United States, especially in the days before electronic records, proving that a person really was who they claimed to be was a huge challenge – until Washington conveniently gave everyone a nine-digit code that no other person living in the country could have.
Like the wings of the proverbial butterfly causing a hurricane on another continent, Social Security law has laid the groundwork for a new kind of more dignified aging in America – as well as a future in which bad people can set fire to to a person’s financial life simply by learning the correct sequence of nine numbers.
The evolution of SSN shows that even the best-designed system can have consequences that are both predictable and completely unintended. Another prime example is the federal government’s five-star rating system for nursing homes.
The New York Times last weekend posted a deep dive on how the Centers for Medicare & Medicaid Services (CMS) measures nursing home performance, and none of the findings should shock those who follow or work in post-acute and long-term care.
Terrible situations, including abuse and neglect, can and do occur in high-ranking institutions. Self-reported staffing data was often inaccurate and exaggerated. Operators often seem to know when inspections could take place, with increases in temporary staff deployed at the right time.
The five-star system, like many other attempts to improve nursing home care and transparency, was started with good intentions. Choosing a long-term care facility for a loved one is a big and difficult decision, and what better way to show comparative quality than the stars – the same way we review restaurants or movies?
Corn the stars are public, which means it’s not just residents and their families who can see the ratings. Many stakeholders may find alternative uses for simple surface level quality measurement.
Over the years, hospitals have realized that star ratings can guide their decisions about referral of their patients for post-acute stays. Managed care plans have found they can build preferred provider networks, with a number of stars serving as a condition of entry. Investors have discovered that star ratings could be an integral part of their valuation calculation, with a stable five-star building commanding a higher price than a one-star facility that could require significant capital and clinical improvements.
It doesn’t matter, as a CMS spokesperson told The Times, whether the five-star system is supposed to be part of the decision-making process for residents and their families. Imbued with all of these new meanings, the ratings went from a practical consumer guide to a five point scale that could make or break a building’s finances. When each additional star brings tangible benefits to investors and operators, it is naive to assume that some industry players, if left on their own, will not find the means to secure them as they can.
To be extremely clear: playing with a federal quality assessment system to address the gaps in care for vulnerable elderly Americans is wrong. But any attempt to solve the problem must take into account that even the simplest solutions can have a range of meanings for people outside the intended audience.
And what about that target audience – residents and their families? The five-star system also regularly fails them.
In 2018, the United Hospital Fund identified a wealth of information that people can’t check out immediately about the nursing home options available to them, such as hospital affiliation, visiting hours, and staff professionalism. The basic questions anyone would ask about a facility designed to care for their parents: How’s the food? Can mom have a private room? Is there a chaplain who performs religious services for dad? – do not have clear answers when an establishment’s performance boils down to five stars.
“I am committed to measuring quality, absolutely, in terms of driving improvements in patient safety and health service delivery, on the one hand,” said Lynn Rogut, director of measurement. quality and transformation of care at the United Hospital Fund. SNN at the time. “And on the other hand, I totally believe that this information is not that helpful to consumers when making health care decisions. These are decisions about the care they want to receive or decisions about the providers from whom they want to receive it.
The solutions are often presented as us versus them. Resident advocates say current rules are not being enforced and fines are too low, and allowing operators to contribute on improvements is tantamount to collaborating with a foreign enemy; industry, meanwhile, predictably burst out in anger when CMS deployed a warning icon for facilities with a recent history of abuse in fall 2019.
The speech is linked to the centuries-old debate surrounding the retirement home inquiry process. Advocates argue that the enforcement is too lax and that the fines are not high enough; Industry leaders say investigations fail to measure the parameters that really matter, the system encourages inspectors to find as many faults as possible, and inspection reports are too often based on preferences and preferences. prejudices of individual investigators.
All the while, potential residents and their family members remain in the dark about what really matters to them.
Like I have argued on current incentives built into the refund system, just about everyone having an opinion on the survey and the quality ratings is correct. Clearly, the current sanctions are failing to improve infection control and staffing; it is clear that there is little public information on the measures of quality of life that really matter to people; it is clear that operators have many non-healthcare incentives to increase star ratings.
The Times investigation comes at a crucial time for nursing home reform in the United States. COVID-19 cases have declined sharply in the midst of the ongoing vaccine rollout, and for the first time in a terrible year, operators and policymakers are ready to anticipate change instead of dealing with day-to-day crises.
In fact, just days after the Times report, California Attorney General Xavier Becerra – soon to be head of the Federal Department of Health and Human Services (HHS) – took legal action against Brookdale Senior Living (NYSE: BKD), alleging that the operator falsified personnel registers in order to inflate the star rating in 10 qualified nursing facilities.
There are several relatively simple fixes to the current system: As with the Payroll-Based Journal (PBJ) program, which replaced self-reported staffing data in the Star System in 2018, CMS could require nursing homes to submit reports. data that officials can more easily. verify or submit reports to more regular audits.
The CMS may include information on nurse turnover and tenure as well as staffing hours, as researchers and the Office of the HHS Inspector General (OIG) recommended. CMS could also develop a series of qualitative measures, based on feedback from consumers and families, to be included alongside more technical data on personnel and quality.
But if there’s a bigger lesson to be learned from last year in long-term care, it’s the story of the social security number. A simple fix can create much bigger problems years, if not decades, and any attempt to put a single number on the quality of retirement homes will simply invite more creative – and potentially dangerous – ways to get around reality to maximize rankings.
Industry leaders and regulators have the power to find real solutions that benefit residents. If we start with what matters most to them, the future of retirement home quality assessments will be more difficult to tap into.