See Part One for an explanation of how I came to understand that a new strategy to disrupt long-term care was called for.
Everyone knows what happens when an inventor builds a better mousetrap– the world beats a path to her door. Except when it doesn’t. Sometimes the incumbents of a particular market don’t want or need something better. The status quo is good enough and the decision to adopt any innovation entails extra work and new risks that are likely to disturb an otherwise stable business proposition. This is the case for most of the long-term care industry. Buoyed by astonishingly low expectations and a reimbursement system that literally pays them for making their patients sicker and weaker, nursing homes represent the one part of our health care system that has seen little substantive change in more than half a century. People don’t buy 1960’s style phones, furniture or cars. They do, however, buy 1960’s era institutional long-term care.
[Footnote: Residents are physically restrained less and, it must be said, chemically restrained more than they used to be.]
Over the past five decades a complex system of supervision and regulation has emerged which is designed to minimize the most egregious failures of the long-term care system. That system was founded upon a decision to think about, regulate and penalize nursing homes in isolation from each other. The regulatory system also adopted a “catch and release” philosophy that emphasizes the work of restoring poorly performing facilities to compliance. The result is a system that everyone dislikes. Providers often feel that they have been singled out for unfair treatment. Regulators become frustrated with the endless cycle of sanction and correction. Elders and their families feel trapped in a broken system that is not serving their needs.
It can be different.
My undergraduate degree was in Biology and although anatomy, physiology and microbiology were among my favorite courses I also enjoyed studying population biology. It was there that I first encountered the idea that herds of wild animals need predators in order to stay healthy. Consider, for example, a herd of 15,000 buffalo roaming the plains with nary a predator in sight. Now imagine that this vast herd is being followed by an enormous team of veterinarians all of whom are dedicated to treating the weak and the sick and returning them as soon as possible to the herd at large. Viewed from the perspective of the individual buffalo this scenario is something close to heaven. From the point of view of the herd, however, it is a disaster of epic proportions.
Predators selectively remove individuals who are weak and sick. Under ordinary circumstances, the strong and healthy have little to fear because predators focus their attention on the weak and the sick. Wolves help keep the herd healthy by removing sources of infection. They help to strengthen their prey by ensuring that weak and malformed individuals do not live long enough to pass their defects on to the next generation. This arrangement is both cruel to individuals and vitally important to the herd.
America’s long-term care system has about 15,000 facilities. Few of them are exposed to anything more than token competition. Meanwhile the industry as a whole is surrounded by an army of consultants and regulators who are dedicated to correcting the flaws of the poor performers and returning them to the general population as soon as possible. We can think of them as a herd that lacks any natural predator. Worse, the ecosystem they occupy ensures that the weak and sick remain as active participants in the industry. This perspective helps explain why even though some individual facilities can and do provide exceptional care, the long-term care “herd” has been, is and will remain disease ridden and highly dysfunctional.
Let’s apply the insights of population biology and wildlife herd management to long-term care and see where they takes us.
What if: State Medicaid authorities and licensing boards stopped coddling the dangerous incompetents and started revoking the licenses of chronic poor performers? Imagine the difference it would make if every state committed to revoking the licenses of the 10, 30 or 50 worst nursing homes within its borders– and they did so every single year. Year after year after year.
What if: CMS stopped begging nursing homes to adopt evidence-based approaches to care and started applying an institutional “death penalty” to the industry’s laggards and dullards? Imagine the newfound interest that the remaining facilities might exhibit toward approaches to care that might protect them from falling into the bottom of the heap.
We need to thin the herd.
Although this policy would be radically unpopular with poor performing nursing homes (and the trade associations that represent them) it would be good for elders and it would greatly benefit the industry as a whole. People want and deserve access to long-term care that is rooted in 21st Century science rather than 19th Century paternalism. Talented professionals need to be able to work for better organizations if they are to rise to their full potential.
For those who ask: “How do you propose to abolish the nursing home?” Here is my answer. I will align myself with a new species of predator, one that delights in preying upon the worst that the long term care industry has to offer. A Tiger is the most cunning, the most daring and the most aggressive when she is hungry. Are you hungry for change? I am.
The time has come to let the Tiger roar.
In Part 3 I explore the contours of the post-nursing home world.