Skilled Nursing News reported on a new study that shows that the Medicaid program may be overpaying operators by billions of dollars per year.  Medicaid is the single largest payor for skilled nursing services, covering about 62% of all nursing home residents according to a 2017 analysis by the Kaiser Family Foundation.  A pair of economists from the University of California, Los Angeles and the University of Georgia published an extensive analysis of Medicaid spending in nursing homes, determining that longer stays in SNFs don’t lead to better outcomes for residents — and thus the government shouldn’t necessarily pay for as many patient days.

“Since we find no evidence that longer stays lead to health improvements, this difference points to Medicaid overspending of … $5,480 per Medicaid stay or about 18.6% of Medicaid spending per nursing home stay,” Martin Hackmann and R. Vincent Pohl wrote in their research, published as an issue brief by the National Bureau of Economic Research. “Multiplying this fraction with national Medicaid nursing home spending of $55 billion in 2015 suggests annual savings of up to $10.2 billion.”

The researchers specifically looked at nursing home residents who started paying for services out of pocket; Medicaid covers skilled nursing care for income-qualified residents, typically after they exhaust their personal resources.  The pair found that nursing homes tend to retain residents longer in periods of low occupancy, but increase discharges of Medicaid beneficiaries once that figure hits around 89%, as they attempt to seek out the highest paying self-funding residents.

“At lower occupancies, nursing homes benefit from extended Medicaid stays, to the extent that Medicaid rates exceed the marginal cost of care. At higher occupancies, this incentive is muted because nursing homes prefer to occupy their scarce beds with more profitable private payers,” they wrote. “In contrast, private payers’ home discharge rates vary little (between 1.7% and 2.1%) and not systematically with occupancy.”

At the same time, the researchers didn’t find a solid connection between longer lengths of stay and health outcomes, noting that the one-year hospitalization rate was actually lower for Medicaid residents at high-occupancy nursing homes, when they were most likely to be discharged.

“Overall, we conclude that marginal Medicaid beneficiaries appear to be relatively healthy,” they wrote. “We also find no evidence that longer stays lead to improved health outcomes suggesting that longer nursing home stays (on this margin) likely constitute over-utilization of nursing home care.”

 

Forget everything you know about “normal” body temperature and fever, starting with 98.6.  There’s no single number for normal. It’s slightly higher for women than men. It’s higher for children than adults. And it is lowest in the morning.  98.6 is an antiquated number based on a flawed study from 1868.  That number was the work of Carl Reinhold August Wunderlich, a 19th-century German physician who wrote a seminal text using data from 25,000 patients. He concluded that 98.6 degrees is the body’s normal “physiologic point,” and that fever begins at 100.4 degrees.  Wunderlich took patients’ temperatures under the arm, a method that produces readings that are lower (and less reliable) than temperatures taken orally, offsetting some of the disparity.

The facts about fever are a lot more complicated. A new study, published online last month in the Journal of General Internal Medicine, refutes the age-old benchmark of 98.6 degrees Fahrenheit. Instead, the study found an average normal temperature in adults of 97.7 degrees, as measured with an oral thermometer.  As for fever, the study shows that it begins at 99.5 degrees, on average.

“A temperature of 99 at six o’clock in the morning is very abnormal, whereas that same temperature at four o’clock in the afternoon can be totally normal,” says Jonathan Hausmann, a rheumatologist at Boston Children’s Hospital and Beth Israel Deaconess Medical Center in Boston, who gathered 11,458 temperatures in crowdsourced research using an iPhone app called Feverprints.

Hausmann believes body temperature to be a flexible concept, viewed in context with age, gender, time of day, and other factors—much in the way weight is evaluated based on height, and how the thresholds for normal blood pressure differ based on age.

In the body’s first response to pathogens, proteins called pyrogens flow through the bloodstream to the hypothalamus, which responds by ramping up the heat. Fever helps your body fight infection by stimulating the immune system, sending a kind of alert to the body’s defenses. It also creates a more hostile environment for bacteria and viruses, making it more difficult for them to replicate.

When someone has trouble breathing in an emergency situation, doctors often employ intubation, a method of helping patients to breathe by inserting a tube down their throat and connecting them to a ventilator to help or replace the process of breathing. Because of its function, many people think of intubation as a miracle procedure — or at least one that works well. It’s supposed to help keep people in serious, painful conditions alive. But, especially for elderly and geriatric patients, that might not be the case.

For an elderly patient, whose condition would be easily weakened or changed, the process of intubation can be particularly invasive. Aside from removing the patient’s ability to speak and sedating them, the process also shows the potential of causing damage and danger to the lungs, throat, and other vital bodily functions.

The New York Times published an article about the unknown dangers of intubating elderly patients at hospitals. It shows, through evaluation of different scientific studies, that elderly patients rarely benefit from intubation. Instead, they are at risk for many more complications as well as pain, injury, and even death as a result of those complications.

In realizing the danger intubation poses toward older patients, doctors have looked to methods of “noninvasive ventilation” as alternatives to intubation, which would cause less physical distress to the body. For example, BiPap devices fall under this category, using a mask over the face instead of a tube down the throat to facilitate healthy breathing. It also gives patients better options in terms of communicating and controlling their own faculties, in addition to running a much lower risk of death or extensive treatment after it’s employed.

When it comes to elderly patients, it’s easy to think of them as an exception. If they don’t naturally react well to a process like intubation, any outsider could think their fragility or susceptibility to pain would be unavoidable due to their age or preexisting conditions. On the other side, family members of elderly patients who have to choose whether to allow intubation are likely to believe their loved one will be an exception to the risks involved in the procedure and follow the more dangerous path.

But these patients don’t necessarily have to live with those risks and pains, and their family doesn’t necessarily have to make such a heavily weighted decision. If innovations in noninvasive ventilation continue to come through, many elderly patients and their families will be saved serious heartache.

The Des Moines Register reported The Centers for Medicare and Medicaid Services refusal to approve Iowa’s so-called “supplemental  payment plan,” a proposal formalized by lawmakers in 2016 without discussion or debate. The plan was just a sleazy windfall for the nursing home industry in Iowa.  Iowa politicians attempted to funnel already scarce Medicaid dollars to privately owned nursing homes that don’t need the money.  Over five years, the plan would have provided 410 nursing homes with an estimated $1 billion in additional taxpayer money. These include homes owned and operated by large, out-of-state, for-profit corporations. Many would have seen their revenue from Medicaid doubled.

The law was written entirely by industry lobbyists, according to Rep. Dave Heaton, R-Mount Pleasant, the bill’s lead sponsor in the Iowa House. It enables county hospitals to hold the licenses of for-profit, independent nursing homes to create the appearance — on paper at least — that the homes are managed by the hospitals.  This hospital “affiliation” would qualify the nursing homes for higher Medicaid payments than they’re currently entitled to collect as independent operators.

For two years, former Gov. Terry Branstad’s privatization of Medicaid has resulted in the loss of care for Iowans and the closing of health facilities. Elected officials at the state and federal level have repeatedly talked about the need to rein in spending on the health insurance program. The last thing public health care dollars should be used for is padding the bottom lines of for-profit nursing homes.

STAT News reported on the pioneering geriatrician Dr. Bill Thomas and the 330-square-foot, plywood-boned home he calls a Minka.  The structure is warm, light, and surprisingly roomy, in a studio loft sort of way. Four oversize windows look out onto the lake, a shed-style roof rising to the view.  In the back corner, across from a big bathroom compliant with the Americans with Disabilities Act, sits a full-size bed. On the other side of a plumbing-filled wall from the bathroom is a kitchen and countertop, made from Ikea components. (The term “Minka” has Japanese origins, as a traditional house for rural dwellers, typically those of modest financial means.)

The idea sounds, in one sense, simple: create and market small, senior-friendly houses like this one and sell them for around $75,000, clustered like mushrooms in tight groups or tucked onto a homeowner’s existing property so caregivers or children can occupy the larger house and help when needed.  The initiative has turned Thomas into a rare breed: the physician homebuilder, and it pits him not only against the nursing home industry, but also the housing industry, with its proclivity for bigger and bigger spaces.

“I spent my career trying to change the nursing home industry,” he said. “But I’ve come to realize it’s not really going to change. So now what I’ve got to do is make it so people don’t need nursing homes in the first place. That what this is about.

Thomas wants to help people grow older on their own turf and terms, while helping spare them the fiscal and physical stress of maintaining  homes.  In so doing, he hopes to shield them from the mouth of a funnel that too often summons elders to a grim march — from independent living, to assisted living, to nursing homes, to memory units, and to the grave.

Thomas said he’s less interested in growing wealthy from the idea than in changing the culture of senior housing.

Reuters reported that nursing home landlord Quality Care Properties Inc has agreed to cut rents for HCR ManorCare.  However, ManorCare, a national for-profit nursing home chain, already owes more than $300 million in back rent and acknowledged it will struggle to pay even the reduced amount, according to a regulatory filing.  Toledo, Ohio-based ManorCare, with more than 250 skilled nursing and assisted living facilities across the United States, is struggling as government Medicaid and Medicare reimbursement rates fail to keep pace with rising costs.  Quality Care, a real estate investment trust (REIT), relies on the nursing home chain for more than 90 percent of its revenues.

Quality Care was spun off in 2016 by larger REIT HCP Inc, which had acquired the ManorCare assets from private equity firm Carlyle Group LP in 2010 for $6.1 billion.  Quality Care shares fell 3.4 percent to $13.54 on Tuesday.

The Daily Beast had an interesting article about the immoral and unethical practice of evicting poor and disabled residents from nursing homes.  “Complaints about allegedly improper evictions and discharges from nursing homes are on the rise in California, Illinois and other states, according to government data. These concerns are echoed in lawsuits and by ombudsmen and consumer advocates.”  In California alone, such complaints have jumped 70 percent in five years, reaching 1,504 last year.  Many patients end up with no permanent housing or regular medical care after being discharged.

Advocates say such decisions are often money-driven, placing profits over people: Medicare covers patients for just a short time after they are released from hospitals. After that, these critics say, many nursing homes don’t want to accept the lower rates paid by Medicaid, the public insurance program for low-income residents.

Among other recent cases of allegedly improper discharges:

*In October, California’s attorney general moved to prevent a Bakersfield nursing home administrator from working with elderly and disabled people, while he awaits trial on charges of elder abuse and wrongful discharge. State prosecutors said one patient was falsely informed that she owed the home money, then sent to an independent living center even though she could not “walk or toilet on her own.”

*A pending lawsuit by Maryland’s attorney general alleges a nursing home chain, Neiswanger Management Services (NMS), illegally evicted residents, sending them to homeless shelters or other inadequate facilities to free up bed space for higher-paying patients.

*Last month, a 73-year-old woman with diabetes and heart failure sued a Fresno, Calif., nursing home for allegedly leaving her with an open wound on a sidewalk in front of a relative’s home. The suit said conditions in the residence were unsafe and a family member refused to allow her inside. The state cited the home in July and issued a $20,000 fine.

Federal law allows a nursing home to discharge or evict a patient when it cannot meet the resident’s needs or the person no longer requires services; if the resident endangers the health and safety of other individuals; or if the patient has failed, after reasonable and appropriate notice, to pay.  The law also generally requires a home to provide 30 days’ notice before discharging a patient involuntarily and requires all discharges be safe and orderly.

 

 

 

U.S. News and other media outlets such as The Daily Mall have reported on the new report that shows an increase in medical doctors specializing in geriatric and nursing home care.  The findings were published Nov. 28 in the Journal of the American Medical Association.  This is great news considering the aging of the Baby Boomers. According to the UPenn study, there are more than 15,000 nursing homes across the country, with a total of about 1.7 million beds. But there are currently 74.9 million baby boomers between the ages of 51 and 69, according to the most recent data from the Pew Research Center.

The number of physicians and health care providers concentrating on nursing home patients grew by about one-third between 2012 and 2015, researchers from the University of Pennsylvania School of Medicine found.

Analyzing Medicare data, the researchers found that the number of doctors, nurse practitioners and physician assistants who were nursing home specialists rose from about 5,100 in 2012 to more than 6,800 in 2015 — about 34 percent.

The Conversation reported on the epidemic of resident to resident assaults in nursing homes.  Many preventable deaths in nursing homes are a result of aggression between residents. This most commonly occurs in people with dementia, their research has found.  Published in the Journal of the American Geriatrics Society, they examined records for all resident-to-resident aggression-related deaths among nursing home residents reported to a coroner in Australia between 2000 and 2013.

Their study examined the frequency and nature of resident-to-resident aggression resulting in the most severe outcome – death. In their analysis, almost 90% of residents involved in resident-to-resident aggression had a diagnosis of dementia. Three-quarters had a history of behavioral problems, including wandering and verbal and physical aggression, which are common symptoms of dementia.

The rising global prevalence of dementia, particularly in the nursing home population, means aggressive behaviors between residents will increasingly be an issue. Two high-level reports on elder abuse in aged care in Australia have recommended better reporting systems so we can understand and prevent all such deaths in nursing homes.

Resident-to-resident aggression is an umbrella term that includes physical, verbal or sexual interactions that are considered to be negative, aggressive or intrusive. These behaviors can cause serious physical harm or psychological distress.

The prevalence of aggression between nursing home residents is difficult to determine. Recent research estimates at least 20% of nursing home residents in the US were involved in such incidents.

Most incidents appeared to be unprovoked, or were triggered by communication issues or a perceived invasion of personal space. Importantly, only one of the 18 studies reported a single death as the result of physical resident-to-resident aggression.

Our research found most exhibitors of aggression (85.7%) were male. The risk of death from aggression between residents was twice as high for male as for female residents. Those who exhibited aggression towards other residents were often younger and more recently admitted to the nursing home than their targets.

Incidents commonly involved a “push and fall”. Seven (25%) related deaths resulted in a coronial inquest, but criminal charges were rarely filed.

However, this is likely to be just the tip of the iceberg as there is much potential for underreporting and misclassification of resident-to-resident aggression deaths. We have limited data on how often incidents of aggression between residents in Australia occur but do not result in death.

WNCN reported that Natalia Mikhailovna Roberts has been accused of stealing medication.  Warrants state Roberts worked as a nurse for Lake Emory Post Acute Care in Inman.  Lake Emory is owned and operated by the national for profit chain Fundamental Long Term Care.

Authorities say there were 78 doses of Oxycodone for a patient when there should have been 96 doses. Warrants state Roberts “intentionally…omitted information” required for records keeping.

Records showed another patient was missing 124 doses of Hydrocodone on June 17, another arrest warrant states.

Roberts is charged with theft of a controlled substance and two counts of violating drug distribution laws by the S.C. Department of Health and Environmental Control.  A temporary order of suspension has been issued for Roberts by the S.C. Department of Labor, Licensing and Regulation.

It is unclear if she was using the pills or selling them to make money.  The investigation into why the facility failed to notice the missing opiods is ongoing.