in part to the exclusion of long-stay nursing home services from the Medicare benefit , Medicaid is the dominant payer of nursing home services , accounting for 50 percent of revenues and 70 percent of bed-days . Medicaid payment rates are typically 70 percent to 80 percent of private-pay prices . In many states , the average margins for Medicaid residents are negative , suggesting the cost of treating Medicaid residents exceeds the amount that Medicaid reimburses for their care .”
As Grabowski and Mor ( 2020 ) explain , “ Medicare is a relatively generous payor , whereas Medicaid often pays below the cost of caring for these frail and medically complex individuals . Thus , the economics of nursing home care hinges on admitting enough short-term Medicare beneficiaries to cross-subsidize the care of long-term residents with Medicaid coverage . Nursing homes that are predominantly dependent on the lower Medicaid reimbursement are poorly resourced , have lower staffing levels , are in poorer neighborhoods , have the most quality problems , and are most likely to close .”
Werner , et al . ( 2020 ) address the changing utilization of long-term care facilities that could impact the fiscal health of the post-acute sector : “ Nursing homes have seen decreasing occupancy for decades , despite the aging of the U . S . population . The number of patients discharged from the hospital to a nursing home for rehabilitation has also declined . To constrain healthcare spending , these patients are being sent directly home , which puts the squeeze on a critical part of nursing homes ’ revenue . Since the pandemic began , short stays have all but vanished , as nursing homes turn away patients after hospital discharge , fearful of an influx of patients with COVID-19 . With Medicare ’ s recent loosening of restrictions on the use of telehealth , it is increasingly possible to support recovery from hospitalization in patients ’ homes , and this approach will most likely outlast the pandemic . At the same time , states have been shifting Medicaid-funded care into people ’ s homes , partially in response to a U . S . Supreme Court decision in Olmstead v . L . C . ( 1999 ) requiring that care be provided in the least restrictive setting possible . Since 2013 , Medicaid has shifted a larger share of care into homes and out of nursing homes , even as it continues to underfund care in both settings .”
Experts say that it is critical for Medicaid to pay a higher rate commensurate with the costs of delivering high-quality long-term care to frail older adults . As Grabowski and Mor ( 2020 ) note , “ Long-term nursing home residents recovering from COVID-19 will require extensive medical and social care . In many states , this will require greater federal contributions . However , this will not be sufficient to ensure access to high-quality medical care for these individuals . Because Medicare still covers medical services for these long-term nursing home residents , models are needed that integrate medical care with the social needs of patients recovering from COVID-19 .”
Grabowski and Mor ( 2020 ) add , “ More engagement of physicians and nurse practitioners in leadership positions in healthcare systems to provide population health to this challenging population is going to be key for any innovation to work because financing reform without delivery system reform is not going be successful . An increasing share of primary care delivered to residents in nursing homes is being provided by specialist clinicians , many of whom are nurse practitioners . This shift has coincided with a reduction in hospital transfers among long-term residents , which helps to make the new financing models viable because reducing hospitalizations makes possible more primary care and other services enhancing quality of life .”
The COVID-19 pandemic has necessitated a paradigm shift , and as Werner , et al . ( 2020 ) assert , “ We are well past due for comprehensive policies that take the care of aging Americans seriously and fund it accordingly and in a wider range of settings . In the short term , nursing homes will have to be saved , because despite their vulnerabilities , they are a necessary part of any solution . Some advocates estimate that it will take up to $ 15 billion in federal funds for nursing homes to survive the COVID-19 pandemic . Recent congressional relief packages have started to address the anticipated shortfall , although experts say they will not be enough . Beyond the pandemic , we will have to transform the way we pay for and provide long-term care . We believe that Medicaid programs need to invest considerably more in care in all settings . As Medicaid has shifted long-term care into homes , funding has not kept up with that trend , meaning that more is demanded of families , who are often responsible for providing informal , unpaid care . An adult child who cares for an aging parent will face losses equivalent to $ 100,000 a year , on average — roughly the same cost as a nursing-home stay . Policies that prioritize home-based care should ensure that it is paid for , whether it is provided by family members or professionals . Many families have wanted to provide care at home even before COVID-19 , and after the pandemic many more may choose to do so if they can afford it … More funding alone is not the answer . Nor is more regulation a sufficient response . Rather , we need a combination of funding , regulation , and a new strategy that fully supports a range of institutional and noninstitutional care .”
The Way Forward Increasing organizational capacity to improve safety and quality is an imperative going forward .
As the Coronavirus Commission on Safety and Quality in Nursing Homes ( 2020 ) emphasizes , “ During the pandemic and every day , nursing home staff are responsible for the care and protection of some of the most vulnerable populations in the nation . The safety and quality of life needs of residents are complex and diverse and require mindful decision-making and effective processes in order to be met . Mindful
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More funding alone is not the answer .
Nor is more regulation a sufficient response .
Rather , we need a combination of funding , regulation , and a new strategy that fully supports a range of institutional and noninstitutional care .”
www . healthcarehygienemagazine . com • aug 2021 • LTC Imperatives Special Issue
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