Lack of Funds Reduces Frequency of Health Inspections

In California, taco trucks are inspected twice a year, outpatient surgery centers an average of once every 12 years.
In California, taco trucks are inspected twice a year, outpatient surgery centers an average of once every 12 years. (By Thor Swift For The Washington Post)
By Gilbert M. Gaul
Washington Post Staff Writer
Monday, July 25, 2005

To understand the gaps in public health inspections in America, consider the taco trucks parked along Harrison Street in San Francisco's Mission District. City inspectors check them at least twice a year.

San Francisco has far fewer outpatient surgery centers than taco vendors. Yet under federal rules, surgical centers have to be inspected only once every six years. In California, even that minimum usually is missed. Inspectors say they get out to the state's 428 surgical centers an average of once every 12 years.

"Would I like to do more inspections? Of course," said Brenda G. Klutz, the state's top health regulator. "The kinds of complicated surgeries that are now being done in ambulatory surgery centers . . . we'd certainly feel better if we were in there more often."

Klutz quickly explains that she can't do more because she doesn't have the money. Unlike cities and counties that rely on user fees and local tax dollars to pay for restaurant inspectors, California and the rest of the states rely on Medicare for most of the money they use to monitor hospitals and other health facilities. And those funds are limited.

Last year, Medicare's budget for policing more than 50,000 facilities -- from big teaching hospitals to tiny hospices -- was $259 million, less than one-third of what it spends in a single day on medical bills.

State regulators say that because federal funding is inadequate and comes with restrictions, they are forced to employ a form of triage. Under rules imposed by Congress, nursing homes must be inspected annually, a requirement that gobbles up about 70 percent of their oversight funds. The result is that thousands of facilities, including outpatient surgery and kidney dialysis centers, go years without review.

Dialysis is one of Medicare's fastest-growing services. It spends about $15 billion a year to rinse deadly toxins from the bloodstreams of patients with failing kidneys. In a report earlier this year, federal officials called the health and safety risks of dialysis "extraordinary" and "life-threatening." Yet centers are supposed to be inspected just once every three years -- and only half of all states are able to meet that minimal standard.

Some state regulators note that mortality rates in American dialysis facilities are 15 to 30 percent higher than those for patients in Europe and Japan.

Thomas E. Hamilton, director of the oversight program for Medicare, acknowledged gaps in inspections but said federal officials are doing "the best that they can with constrained resources. Our job is to ensure that we get the maximum benefits for the dollars that are appropriated."

Hamilton said Medicare officials have prioritized inspections into four tiers, with nursing homes in the first tier and outpatient surgery centers at the bottom. The system is set up so that if states find they don't have enough funds, "they cut back on the lowest priorities first."

He added that Medicare officials are making adjustments because of concerns that some facilities aren't being inspected. As part of that effort, they plan to target a small number of dialysis centers for more frequent visits. "The idea is that it isn't all or nothing based on the tiers," he said.

The flaws in the inspection system don't stop at funding. When state regulators do turn up problems, they often run into obstacles trying to get them corrected.

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