Nursing home residents infected by COVID-19 are approximately five times more likely to die than a person of the same age living at home. Nursing homes and other long-term care facilities make up about 33% of all COVID-19 deaths nationwide. As of last week, over 163,000 residents and employees of nursing homes and other long-term care facilities had died.
Even before the pandemic, many facilities had quality control issues. The Health and Human Services Office of Inspector General noted that “[a]s of February 2020, State Survey Agencies have cited more than 6,600 nursing homes (nearly 43%) for infection prevention and control program deficiencies, including lack of a correction plan in place for these deficiencies.” After the COVID-19 outbreak, the lack of the nursing home industry’s resources directed to mandated requirements for effective prevention and control programs contributed to a fundamental lack of preparedness, sometimes with deadly consequences. In Pennsylvania, more than 700 nursing homes house more than 80,000 residents.
Nursing homes provide custodial care that includes basic care not available at home or in assisted living facilities. Most nursing homes also provide “skilled care” services such as post-acute-surgery care, behavioral and psychiatric care, treatment of complex comorbid conditions including respiratory and renal diseases, and wound care. Unfortunately, the management of these residents’ complex and acute conditions, concurrent with standard everyday care, results in managers (and an often-under-trained workforce) performing far too many tasks to provide sufficient care. Medicare, managed-care organizations, and insurance companies regularly reimburse these “skilled care” residents at a rate three to 10 times higher than for custodial care.
That payment system is crucial to understanding how we got here. The April and mid-December COVID-19 surges demanded that hospitals and surgery centers reduce surgeries and admissions for acute care, which significantly reduced the number of nursing home residents reimbursed at the higher skilled-care rates. With this reduction, homes were cascading toward financial failure. As Kaiser Health News reported, “many nursing homes in the U.S. are fighting against two crises: the pandemic that is sickening and killing residents as well as the possibility of bankruptcy.”
Beginning in late spring 2020 and continuing into this year, the momentum toward financial ruin was mitigated somewhat by “provider relief” funding totaling approximately $10 billion. But this funding is a temporary reprieve, not a long-term solution to reduced revenue, alongside the burden of large non-operational payments to investors, operators, landlords, real estate trusts, and management companies.
The nursing home industry is also susceptible to owners and operators who are laser-focused on profits over quality care. There is nothing wrong or illegal with making money. What is illegal is siphoning money that “knowingly” leads to claims for payment by the government for care that was never rendered, or was grossly negligent.
Still, we can do better—and save more lives.
First, Medicare and Medicaid and other funders must tie facility reimbursement to quality of care and safety while appropriately funding rule enforcement. Federal, state, and local groups working with providers need a strategy that identifies the worst performers in the industry and, after reasonable attempts at compliance have failed, expedites termination of their participation in government programs. The imposition of monitors by the state is an especially important remedy. And regulators cannot be afraid to remove owners who have shown reckless disregard for vulnerable residents through the appointment of temporary managers.
Second, federal and state governments should provide additional funding for custodial care. Pre-existing nursing home staffing shortages have been exacerbated by the deadly effects of COVID-19 and must be remedied. Concurrently, as proposed in the Biden administration’s 2021 Economic Recovery Plan, federal funding must be provided to pay at-home and community workers a fair wage and offer them training, while providing caregivers and patients supporting medical services and equipment. This effort requires increased federal funding and expanded state programs to enable a safe and quality care home alternative (e.g., the currently underfunded Medicaid home and community care waiver programs).
The Pennsylvania Department of Health is revising its nursing home licensure regulations. This is an opportunity to advocate for nursing home residents who deserve to be treated with dignity and respect. Quality care and safety is the first and only priority.
These residents are our family members and friends. Someday, we will be in these homes. We must act on that which generations of change agents demand of our efforts at protecting society’s vulnerable and put people before profits.
David R. Hoffman is President of David Hoffman & Associates, PC, a national health care consulting firm assisting health care providers to comply with regulatory requirements and ensuring patient safety through legal and clinical compliance, and practice professor at Drexel University’s Thomas R. Kline School of Law. Jerry Seelig, CEO of Seelig+Cussigh HCO LLC (S+C), has been appointed to rapid-intervention leadership positions for over 40 health care providers, serves as consultant to L.A. Care, and publishes the weekly long-term care newsletter Revitalize.