Beginning in mid-March, coronavirus deaths surged across much of the country, peaking above 10,000 per day.  We still have not returned to normal death rates. The overall confirmed number is 100,000 but the true count is even higher — closer to 135,000. This larger number includes people who had the virus but weren’t diagnosed before they died.  This includes thousands of nursing home residents.

Alex Spanko for Skilled Nursing News wrote a great article about the financial structure that is the shaky foundation of long term care in America.  “At the base, Medicaid supports long-term care residents who can no longer live on their own without around-the-clock care.  Medicare dollars pay for higher-acuity care that seniors require after hospital stays — and prop up insufficient Medicaid reimbursements that can’t financially sustain a nursing home on their own.”

To protect themselves from liability and ambitious plaintiffs’ attorneys, operators covered up the windows to their offices with complex webs of intertwined ownership and management companies that even veteran journalists have struggled to unravel.

While such legal maneuvering is common and generally accepted in any industry with a significant real estate component, the nature of the clients that nursing homes serve — and the occasional horrific stories of serious lapses in care — made the media and the public deeply suspicious of what exactly was going on behind the curtain.

Then the hurricane-force winds of the COVID-19 crisis blew the whole structure down.

No one paying attention to the news, and watching the rapidly climbing coronavirus death toll at our nation’s nursing homes and other long-term care facilities, can be blamed for being angry. My own blood pressure spikes when I go through my inbox each morning, scrolling past story after story about shortages of protective equipment and temporary morgues in refrigerated trucks.

The federal government has taken some positive steps — restricting visits and focusing on infection-control inspections early in the process chief among them. While the industry itself has been out in front of CMS in many aspects, especially around calls for greater transparency about the number of reported cases, these steps reflect some understanding of how serious the situation would get, even before “social distancing” became a nationwide edict.

But the administration’s inability to coordinate the distribution of personal protective equipment (PPE) and COVID-19 testing kits represents a profound failure. In the United States, nurses should never have to use garbage bags and ponchos to protect themselves and their patients. In the United States, everyone should be able to receive testing during a pandemic, but CMS and states should have pushed nursing homes to the front of the line at the very first signs of danger.

Clearly, we are in unprecedented times, and well-meaning officials are going to make mistakes as they work to fight an unseen enemy. It’s just one example, but it reveals the deep tensions that exist between state and federal oversight of nursing homes, both from a regulatory and payment standpoint.

Operators must rely on the perfect combination of federal Medicare dollars and state-level Medicaid funding to survive. The two care models that those funds support couldn’t be more different, but persistent Medicaid shortfalls have made providing both short- and long-term care a necessity.

Without the Medicare money, a building simply can’t support itself or its residents on Medicaid alone — but as COVID-19 has revealed, bringing post-acute residents into a setting with even more vulnerable long-term care patients can be a recipe for disaster.

Once the danger passes, lawmakers at all levels need to deeply question the ways that federal and state rules around nursing homes overlap and diverge. Big-picture thinkers have long predicted the development of a site-neutral model, but it’s time to seriously consider a single federal payer source for all types of long-term and post-acute care. A split Medicare-Medicaid model, born largely by accident and sustained by inertia, falls apart in a crisis.

When the coronavirus crisis abates — and operators and caregivers are no longer pleading for access to PPE and testing — my personal hope is that providers, lawmakers, and investors take seriously the opportunity to reflect on the failures baked into the system.

Maybe it’s finally time to prioritize across-the-board increases in wages for the people who have spent this crisis putting themselves and their families at risk, even if it’s at the expense at profit margins — temporary hazard pay and one-time stipends aren’t enough to fairly compensate these essential workers.

Maybe it’s finally time to embrace wholesale changes to payment models, instead of perceiving each tweak and update as an attack on the heart of the industry.

Maybe it’s finally time to tear down the wall of suspicion and derision that leaders on both sides have built up between the public and nursing home operators.

 

At least 30,000 residents and workers have died from the coronavirus at nursing homes and other long-term care facilities in the United States. Confirmed cases of the virus have infected more than 175,000 residents at 7,700 facilities.  While just 11 percent of the country’s confirmed cases have occurred in long-term care facilities, deaths related to Covid-19 in these facilities account for more than a third of the country’s pandemic fatalities.  In 14 states, the number of residents and workers who have died accounts for more than half of all deaths from the virus. Because of the poor testing in South Carolina, nursing home deaths amount to 32% of all coronavirus deaths.

The Trump Administration still has not tallied the number of nursing homes that have had outbreaks nationwide or the number of residents who have died. And the data is still weeks away from being made public, according to the Centers for Medicare and Medicaid Services, or CMS, the federal agency that oversees nursing homes.  Given the wide variability in the type of information available, the totals shown here almost certainly represent an undercount of the true toll.

The nursing home industry says knowing the scope of the problem and which facilities should get priority is crucial. The need for greater access to testing and protective equipment has become even more urgent as more states are beginning to ease restrictions and reopen, effectively leaving older Americans “to fend for themselves as the virus threatens to wipe out an entire generation,” LeadingAge, which represents nonprofit long-term care facilities, said in a statement.

Under the new requirements, long-term care facilities must begin reporting coronavirus cases and other data to the federal government by May 17 or face monetary penalties. However, they will initially have a two-week grace period to comply, according to CMS.

From TMZ

A hot mic picks up someone telling the Veep, “Those are empty, sir. We’re good to go.” The VP then shot back, “Well, can I carry the empty ones? Just for the camera?”

In some cases, it means that organizations might get out ahead of CDC on some infection control practices,” Feifer said. “And in some cases, that may turn out to be unnecessary. But it’s better to risk overreacting in the face of this pandemic than to risk under-reacting, or being a little bit too late — because lives are at stake.”

 “We are learning on the fly; we’re sharing with one another across the industry in ways that are truly extraordinary, and we’re having to figure out answers to new problems on a minute-to-minute basis. Some of our biggest challenges right now involve access to testing patients with potential coronavirus disease, as well as the supply of personal protective equipment — especially masks and gowns to keep both the staff safe, as well as the residents.”

“We’re all struggling with the national shortage of PPE. Everyone’s experiencing that, and everyone’s dealing with it in somewhat different ways. Across Genesis, we’ve been able to maintain a supply of standard face masks, and N95s, for situations where there’s high risk and when they’re needed — and gowns, up until this point. And we’ve done that largely by going to various sources around the world to obtain supplies where we can, when we can, and by shifting supply around among our various facilities all around the country — from areas that don’t need quite as much, as they’ve been able to obtain, to facilities that do because they’re in hotspots.

That’s getting us by on a day-by-day basis. But that’s not sustainable. The nation’s shortage is going to reach a critical point at some point in the next few weeks, and then we’re going to be looking at alternatives that are certainly not preferable — but they may be necessary backup plans. So you mentioned using somewhat unusual coverings, whether it’s garbage bags, or raincoats, or what have you. We are not at that point yet, and we hope to not get there.”

“There is a huge gap related to the access of testing in skilled nursing facilities today — and any suggestion otherwise fails to see what’s actually on the ground in America’s nursing homes. And that gap is costing lives. I can’t say it any more clearly. This is deeply concerning.”

There is a shortage of the swab kits that the laboratory suppliers to nursing homes are telling us on a daily basis — and that shortage has been getting worse day by day, not better. And even when we can obtain the swab kits, the turnaround time for labs for nursing homes ranges from three days — that’s the fastest — up to 11 days. This is completely unacceptable. We need to sound the alarm nationally. One of the principles of epidemic management that we’re focused on is cohorting patients — cohorting patients who are positive for coronavirus disease away from those who are not. That’s optimal in separate facilities, where there’s no risk of spread within a facility. But cohorting is the principle, and you can’t cohort patients if you can’t know with reasonable certainty who has the disease and who doesn’t.

 We need to all be creative. We need to use our best judgment. We need to put safety and infection control first. That, right now, is all that matters. And in some cases, it means that organizations might get out ahead of CDC on some infection control practices. And in some cases, that may turn out to be unnecessary. But it’s better to risk overreacting in the face of this pandemic than to risk under-reacting, or being a little bit too late — because lives are at stake. It’s always easier to back off on an intervention if it turns out not to be effective or not practical or not necessary. But you can’t turn back the clock and start doing something a few weeks ago if we learn later how important it is, and we missed the boat.

 

Guardian Elder Care Holdings was owned and controlled by Peter Varischetti.  He settled with the federal government because whistle-blower complaints proved he provided unnecessary rehab therapy to residents – some with dementia or in hospice care – to make money, overlooking clinical needs of patients.  The care they received was “medically unreasonable, unnecessary, unskilled and possibly harmful,” the civil suit said.

U.S. Attorney Scott Brady said in a news release Guardian Elder Care pressured its therapists to provide gratuitous services for a higher Medicare reimbursement from 2011 through 2017.

Too much rehabilitation therapy can actually harm patients, just like giving them too many pills or too much medicine,” said U.S. Attorney William McSwain. “And of course it harms taxpayers who foot the bill for unnecessary treatment.”

Guardian only had to pay back $15.5 million to settle claims the company provided dangerous services for more profit.  In addition to paying $15.5 million, Guardian entered into a “corporate integrity agreement” with the U.S. Department of Health and Human Services to “encourage future compliance”.  Hold on.  What.  They are still letting this criminal operate a nursing home? Ridiculous.

The heroes are the two former Guardian employees who were whistle-blowers under the False Claims Act, which permits citizens to sue on behalf of the United States and share settlement money.

 

We see it all the time where a nursing home’s doctor has a bias against one of our clients because of race, gender, or sexual orientation. It clearly affects their ability to testify honestly and consistently with accepted medical practice.  A recent article from the New York Times explored bias in missed medical diagnosis.  Bias, which takes many forms, affects how doctors think and the treatment decisions they make.

Racial biases in treatment decisions by physicians are well documented. One study found that black patients were significantly less likely than white patients to receive pain medication in the emergency department, despite reporting similar levels of pain. Other research suggests that racial biases among providers contributed to racial differences in patient trust in the health system.

A growing body of scientific research on physician decision-making shows that doctors exhibit other biases as well — cognitive ones — that influence the way they think and treat patients. These biases lead doctors to make the same mistakes as the rest of us, but usually at a greater cost.  Cognitive biases refer to a range of systematic errors in human decision-making stemming from the tendency to use mental shortcuts.

Prominent examples include confirmation bias, the tendency to interpret new information in a way favorable to one’s preconceptions; and anchoring, the tendency to overly weight an initial piece of information, even when order does not matter.  In health care, such biases can  affect whether similar patients live or die.  A recent study analyzed gender bias in surgeon referrals and found that when the patient of a female surgeon dies, the physician who made the referral to that surgeon sends fewer patients to all female surgeons in the future. The study found no such decline in referrals for male surgeons after a patient death.

In a new study of physician treatment decisions published in The New England Journal of Medicine, signs of left-digit bias are investigated. Left-digit bias could affect many clinical decisions. For example, patients with hemoglobin levels of 9.9 grams per deciliter may be perceived as being substantially more anemic than patients with hemoglobin levels of 10.0 grams per deciliter (the difference in the two values has no clinical significance).The study confirms previous work that found doctors are overly responsive to patient age when diagnosing illness, and that showed how seemingly irrelevant factors‚ such as the difference of a few weeks of age, could govern physicians’ decisions about treatment, with potentially life-altering consequences for patients.

Howard Gleckman wrote a great article about nursing home closures.  4 percent of nursing facilities closed from 2015 to 2019.  There still are more than 15,000 nursing facilities in the US.  Gleckman argues that nursing homes are shutting their doors at a rapid pace because of growing pressures from payors, rising costs, the need to replace old buildings, increased competition from other forms of residential care, and shrinking demand from older adults who prefer to age at home.

“A new study by the senior services trade group Leading Age reports that more than 550 nursing homes closed over the past four years, and that the trend is accelerating. More than half occurred in nine states—Texas, Illinois, California, Ohio, Massachusetts, Wisconsin, Kansas, Nebraska, and Oklahoma. The Leading Age report was primarily based on government data. It measures closures but does not count new facilities that opened over the period.”

“A separate study by the National Investment Center for Seniors Housing & Care (NIC) ——based on an ongoing industry survey— helps explain the trend: Occupancy rates in skilled nursing facilities have been falling since 2015, though they stabilized over the past year. Medicaid, which pays the lowest average rates, represents a growing share of residents, while relatively fewer patients are covered by traditional Medicare—the most generous payor.”

NIC found occupancy rates have fallen from a peak of about 89 percent in 2015 to about 84 percent today. Leading Age reported the number of occupied beds fell by 16,000 over the same period, to about 1.325 million.

“At the same time, Medicaid residents grew from about 60 percent of volume in 2015 to 68 percent last year, traditional Medicare fell from about 18 percent to 11 percent, and managed Medicare grew slightly to about 6.5 percent. The share of lucrative private pay residents dropped from about 11 percent to 8 percent.”

“For years, the financial model of nursing facilities has been built on a system of government cross-subsidies. The facilities lost money on their Medicaid long-stay beds but made a healthy profit on their Medicare post-acute business. But as Medicaid payments fall further behind costs and Medicare managed care continues to squeeze margins, that business model is at risk.”

 

 

 

“As of today, the youngest of the nearly 70 million baby boomers is 55; the oldest is 74. Within the next decade, millions of them will need long-term care. Many will remain in their homes, with family or “drop-in” caregiver services lending a hand. Some will move in with relatives. Those who are most dependent on care might choose nursing homes. A diverse and expanding older population is looking for help.”

The National Interest recently had a fantastic article on the need for long term care for the Baby Boomers and the lack of regulation and oversight of the assisted living industry.  The problem is that some ALFs provide care and assistance and may even have secured dementia units while others provide minimal or no assistance based on an admission assessment that needs to be updated and evolve as changes of condition warrant.  The inconsistency can affect expectations and give a false sense of security.  More options need to be explored.  The National Interest analyzed data about what information was available to consumers.

“Unlike nursing homes, which are regulated by the federal government, the states oversee assisted living; they define what constitutes an assisted living residence, establish licensing requirements, and set quality standards.”

“Data from the states on assisted living is provided free to the public. All licensed residences are listed. While private search services might help consumers sort through options, it’s not clear how complete – or objective – they are. Some services exist primarily for marketing purposes; they collect fees from the residences they list.”

“Using criteria formulated from prior research, along with information provided by some states, we examined 39 key elements of each website. Those elements included the size of the facility, cost, license status, the insurance it accepts, and any special services offered, such as memory care. We also looked at each website’s usability – the ease in finding critical information.”

The conclusion: “True, the state websites are better than they were 15 years ago. But they are less than what they should be. Many of the elderly, the disabled, and the families who love them require more to make appropriate choices. When navigating the internet, the principle of “buyer beware” should not be the driver.”

The U.S. Attorney’s Office in Northern District of Iowa released the following:
Falsely Stated He Was Spending More Time with Patients in Nursing Homes Than He Was Actually Spending With Them

Dr. Joseph X. Latella, a primary care doctor in Webster City, Iowa, was sentenced today to two months in prison and to pay a fine after previously pleading guilty to making false statements related to health care matters.  Dr. Latella has also agreed to pay $316,438.96 to resolve False Claims Act allegations relating to claims he submitted for routine visits for nursing facility residents between January 1, 2014, and November 30, 2018.  The United States alleged that Dr. Latella submitted claims to Medicare and Medicaid for the most intensive and expensive claim code for such visits when, in fact, he was not performing services sufficient to justify use of that code.

Dr. Latella admitted in a plea agreement that, in June 2018, the United States Attorney for the Northern District of Iowa was conducting a civil investigation about concerns that Dr. Latella was “upcoding” claims submitted to Medicare and Medicaid and billing for more intensive visits with patients at Webster City area nursing homes than he had performed.  The United States Attorney’s investigation indicated that Dr. Latella was billing over 93% of his nursing home visits to Medicare under the most intensive and expensive claim code.  For these claims to be valid, a doctor typically must spend 35 minutes at the patient’s bedside and on the patient’s facility floor or unit.  Medicare paid more than $94 for these claims, but would only have paid no more than $32 if the least expensive claim code, for routine ten minute visits, had been billed.  In July 2016, a Medicare contractor sent Dr. Latella a letter warning him that his billing patterns were significantly more expensive than other doctors.

In July 2018, Dr. Latella submitted sworn written answers to the United States Attorney, in which Dr. Latella falsely declared that, with respect to certain Medicare claims in 2017 and 2018, he had spent approximately 35 minutes for each of 12 patients’ care at two nursing homes.  With respect to one particular date in October 2017, Dr. Latella falsely swore he “started visiting the nursing home patients at 7:30 a.m. and completed my visits with each patient at approximately 5:30 p.m.”  In truth, a federal agent had conducted in-person surveillance of Dr. Latella on that date, and Dr. Latella only was on site at the first nursing home for a total of 47 minutes and did not visit the second nursing home at all on that date.  The administrator of the first nursing home estimated that Dr. Latella spent approximately five minutes with each nursing home patient during his visits to that nursing home.

Dr. Latella made further false statements about claims in January and February 2018, which the Medicaid Fraud Control Unit discovered through videotaped surveillance.  For example, Dr. Latella billed nine claims for services allegedly provided to nine Medicare patients, on February 2, 2018, at a nursing home, but the surveillance showed that Dr. Latella was only on site at the nursing home for a total of 14 minutes.

Dr. Latella provided the United States Attorney with fraudulent, re-created treatment notes in order to cover up his overbilling scheme.  Dr. Latella’s staff had a practice of shredding all notes for all nursing home patients immediately after billing the taxpayers for those services; at the time of the audit, therefore, Dr. Latella had no records of any of the treatment he had ever provided to patients at the nursing homes.  To re-create the notes, Dr. Latella contacted the nursing home administrators and nursing managers of various nursing homes and asked for copies of patients’ charts.  In truth, elderly residents of nursing homes did not receive the care for which taxpayers paid him, and these vulnerable nursing home residents’ family members cannot know whether and to what extent those nursing home residents received medical care from Dr. Latella over the years.

Dr. Latella was the medical director of two nursing homes at which he was billing fraudulently.  Dr. Latella also was the Hamilton County Coroner, provided services to inmates in the Hamilton County Jail and in the custody of the United States Marshal’s Service, and he also evaluated workers’ compensation claims for a major Webster City employer.

In total, Dr. Latella admitted that, between January 1, 2014, and November 30, 2018, he submitted 1,140 false claims to Medicare, which were not justified, and he was paid $107,980.59 by Medicare for those claims.  Dr. Latella also admitted that he caused Medicaid to make unjustified payments in the total amount of $9,218.73 for these claims.  As a part of his plea agreement, Dr. Latella has agreed to pay no less than $107,980.59 to Medicare and $9,218.73 to Medicaid for economic losses caused by his commission of the offense.

“Like all providers, doctors who treat Iowa’s elderly population have a duty to provide needed medical services and bill accurately for those services.  By his alleged actions, Dr. Latella scammed the healthcare system and left his elderly patients and their families wondering if the patients received care they needed,” said Peter E. Deegan, Jr., United States Attorney for the Northern District of Iowa.  “When our office’s civil investigators made an official inquiry into his billing practices, Dr. Latella tried to throw the government off the scent by lying and creating false records.  This settlement and prosecution demonstrate my office’s focus on ensuring Medicare and Medicaid beneficiaries receive the care to which they are entitled, public monies are well spent, and individuals or entities responding to my office’s civil investigative demands provide complete and truthful responses.”

“Government health care rules require bills be submitted only for services actually provided – anything more is fraudulent and a disservice to patients needing vital care,” said Curt L. Muller, Special Agent in Charge for the Office of Inspector General of the U.S. Department of Health and Human Services.  “We will continue to protect the integrity of government health care programs and taxpayers funding these vital services by holding providers fully accountable.”

The civil matter arose from an affirmative investigation. False Claims Act cases can also be brought under the qui tam provisions of the Act, which encourage whistleblowers to bring suit on behalf of the United States and share in any financial recovery.  The civil case was handled by Assistant United States Attorneys Melissa Carrington and Jacob Schunk.  The criminal case was prosecuted by Assistant United States Attorney Tim Vavricek.  The cases were investigated by the Department of Health and Human Services, Office of the Inspector General, and the Iowa Medicaid Fraud Control Unit.