Nursing home residents are increasingly spending time in rehabilitation treatment during the last days of their lives, subjected to potentially unnecessary therapy that reaps significant financial benefits for cash-strapped facilities, a study shows.
The proportion of nursing home residents who received “ultrahigh intensity” rehabilitation increased by 65% from October 2012 to April 2016, according to research published this month by the University of Rochester. Medicare defines “very high” therapy as almost nine hours per week, and “ultrahigh” therapy as more than 12 hours per week. Some residents were found to have been treated with the highest concentration of rehabilitation during their last week of life.
The study analyzed data from 647 New York-based nursing home facilities and 55,691 long-stay decedent residents, with a specific focus on those who received very high to ultrahigh rehabilitation services—including physical, occupational and speech therapy—during the last 30 days of their life. Such treatments garner the biggest payouts from insurers. The study sourced data from New York nursing homes’ Minimum Data Set assessments, which track a patient’s health status and socio-demographics, as well as the Centers for Medicare and Medicaid Services’ (CMS) Nursing Home Compare website.
The findings raise questions about financial motives, said Helena Temkin-Greener, the lead author of the study and a professor at the University of Rochester Medical Center Department of Public Health Sciences. Medicare, a federal insurance program, doles out lofty reimbursement checks to nursing homes with patients facing the most complex and time-intensive rehabilitation. Temkin-Greener said for-profit nursing homes were more than two times as likely to use high to ultrahigh intensity therapy than were nonprofit homes.
“There’s a possibility that nursing homes know a patient is approaching end of life, but the financial pressures are so high that they use these treatments so they can maximize revenue,” she said. Alternatively, “if it’s being driven by a failure to recognize that a resident is approaching end-of-life, then it calls for improving the skills of nursing home teams.”
“If ultrahigh therapy is good for patients at end of life, why are only for-profits using it?”
The New York State Department of Health, the Office of the New York Attorney General, and the Centers for Medicare and Medicaid Services didn’t return requests for comment.
“It is important for [skilled nursing facility] providers and their care teams to consider the risk-benefit of potential therapy interventions and dosage relative to the resident’s current health status,” said Daniel Ciolek, associate vice president of therapy advocacy at the American Health Care Association, which represents most of the country’s for-profit nursing homes. Ciolek noted the AHCA has long promoted efforts to redesign the skilled-nursing facility payment system to “be based on care needs, rather than service delivery.”
Associations representing nonprofit nursing homes agreed. “Reimbursement policy should be driven by what it costs to provide high-quality care to all Medicare beneficiaries,” said Aaron Tripp, the director of long-term care policy and analytics at LeadingAge, an organization that represents more than 2,000 nonprofit nursing homes. “If someone comes into a skilled nursing home facility with high degrees of medical complexity but not in need of rehab, they shouldn’t be at a disadvantage because the system provides incentives for patients in need of high therapy.” LeadingAge has criticized the current patient-classification system, which determines reimbursement levels for skilled nursing facilities (SNF), since it was rolled out in 2010.
Ciolek pushed back against the new study’s methodology, which he said defined a very narrow SNF population of long-stay residents. He said the study gives a false impression that the findings apply to all SNF admissions. Temkin-Greener said the research “clearly focused on long-term decedent residents for whom high-intensity therapy delivered at the end of life is not indicated. However, with about 30% of all Americans dying in nursing homes, this can hardly be described as a ‘very narrow SNF population.’”
The study of New York facilities doesn’t bode well for how nursing homes throughout the U.S. are treating dying residents—given that most states have less stringent nursing home regulatory oversight than New York. “This is a nationwide problem,” said Paul Ginsburg, director of the USC-Brookings Schaeffer Initiative for Health Policy. “I would suspect this isn’t unique to New York, since these distortions in our payment system are national.”
Rehabilitation therapy has proven to be incredibly beneficial to patients when properly prescribed, Temkin-Greener noted, but with those approaching death, high-intensity treatment might be preventing staff from providing more appropriate end-of-life care, such as hospice or palliative care. It may also be accelerating the residents’ decline.
There’s one particular piece of data from the study, she said, that points toward nursing homes seeking to profit from helpless residents. “If ultrahigh therapy is good for patients at end of life, why are only for-profits using it?” Temkin-Greener asked. “These people are using high-intensity services without justification.”
“In a perfect world, the new model would help mitigate this.”
The Patient-Driven Payment Model
Forthcoming Medicare payment and policy changes for skilled nursing facilities may end the very incentives that encourage high-intensity treatment. Starting Oct. 1, 2019, CMS will implement a new ‘Patient-Driven Payment Model’ that will determine payments based on a patient’s condition and health needs, rather than on the amount of care provided or the intensity of treatment. The Medicare Payment Advisory Commission, an independent U.S. federal body, applauded the decision.
“It will level the playing field, so there won’t be the financial incentive to have therapy drive payment as much as it does today,” Tripp, of the nonprofit industry group, said. “In a perfect world, the new model would help mitigate this. But it’s too early to say.”
The aging of the baby boomers could eventually increase future use of nursing home care, but the people who are ages 85 and older now are members of the relatively small “Silent Generation,” not the baby boom generation, and they are taking advantage of opportunities to stay in their own homes, or in relatively home-like assisted living center apartments and houses, for as long as possible.
Nursing homes have seen the number of patients decline in recent years. Occupancy is at roughly 85%, a 5% drop from 10 years prior, according to recent data from National Investment Center for Seniors Housing and Care. About one in five beds in a skilled-nursing home goes unused. Meanwhile, nursing homes are closing at unprecedented rates across the country.
Ginsburg said the decline in occupancy isn’t likely to be contributing to the increase in high-intensity treatment. “It doesn’t matter if the beds are empty or not,” he said. “The incentives to do too much rehabilitation exist whether a facility is under-or over-occupied.”
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