[co-author: Bruce Chernof, M.D., President & CEO, The SCAN Foundation]
Editor’s Note: COVID-19 has reaped a horrific toll on our nation’s 2.5 million nursing home residents and their families. People living in nursing homes make up less than 1 percent of the U.S. population yet account for approximately 40 percent of all COVID-19 deaths to date.
Others who rely on long-term services and supports (LTSS) also have been disproportionately affected. Medicare beneficiaries who also are eligible for Medicaid contracted and were hospitalized for COVID-19 at more than four times the rate of non-dually eligible Medicare beneficiaries; about half of dual eligibles use LTSS. Similarly, people with developmental disabilities living in group homes are four times more likely than the general population to contract COVID-19 and twice as likely to die from it.
In a new article posted on the Health Affairs blog, summarized below, The SCAN Foundation and Manatt Health discuss how the current public health crisis has exposed underlying weaknesses in the LTSS system and the actions that providers, state and federal administrators, and policy makers will need to take to drive bold and lasting changes. Click here to read the full blog post.
The Warning Signs
The first major COVID-19 outbreak in the United States was in a nursing home in Kirkland, Washington, in late February. The fact that the first significant outbreak occurred in a nursing home was a warning sign.
As the pandemic progressed, it also became clear that COVID-19 was having a disproportionate impact on communities of color. That, too, should have been no surprise given health inequities and the greater likelihood that minority and low-income people are doing “essential” work that puts them in harm’s way. These inequities didn’t arise simply because of the way in which COVID-19 took its toll. COVID-19 exposed underlying weaknesses that already existed in the LTSS system.
Let’s start with financing. Medicare pays only for short-term use of nursing home and home health services, and private insurance for LTSS is very limited. Medicaid, the single-largest source of funding for LTSS, kicks in only after people deplete their resources. With no federal floor on Medicaid rates or minimum staffing and wage levels, state-set Medicaid rates for nursing homes, at about $200 per day, are lower than they are for other payers. Low reimbursement levels have translated into outdated facilities and a workforce that is poorly paid and lacks benefits, such as paid sick leave, as well as the training needed to care for people with multiple chronic illnesses.
Despite all that is at stake, LTSS oversight is weak at both the federal and state levels. For example, 82 percent of nursing homes were found to have a deficiency in infection prevention and control at some point between 2013 and 2017. In addition, for-profit entities now dominate the nursing home industry, with some acting more as speculators than as healthcare providers. Regulators are often ill-equipped to ensure that revenues are devoted appropriately to direct care.
Strong and immediate steps are needed to prepare for the next wave of infection. At the same time, we must reimagine and invest in a more resilient, person-centered LTSS system that operates as part of the healthcare continuum.
The Path Forward
In the immediate and near terms, providers and state and federal administrators and policy makers will need to take quick and decisive action in light of new COVID-19 outbreaks. States experiencing infection surges for the first time can learn much from other states. This includes quickly implementing plans to isolate COVID-19-positive residents, considering wage increases and paid sick leave for staff, ensuring personal protective equipment for all workers, and providing a strategic testing plan for residents and staff. No facility should accept COVID-19-positive hospital discharges unless basic infection control measures are in place, which might require opening supplemental facilities.
The work of strengthening the LTSS system for the future will require a longer-term commitment from states, providers and the federal government, focusing on the areas below.
Accelerate efforts to expand access to home- and community-based LTSS. Too often, institutional care remains the only option. Change requires rethinking when and how options are presented and integrated into an individual’s care plan as well as creating more options.
Strengthen the ties between LTSS and the rest of the healthcare system. Integration strategies can use a variety of approaches, including more person-centered care planning, investments in health information technology infrastructure and telehealth, and bringing direct care workers onto care planning and clinical teams.
Replace aging and outdated facilities, particularly in low-income communities. Nursing homes and other institutional settings should be smaller, with single-occupancy rooms and low staff-to-resident ratios.
Reform federal and state regulatory oversight of nursing home providers and quality. This will promote transparency in provider ownership, strengthen survey and certification rules, and ensure meaningful penalties for noncompliance with these rules.
Seriously explore sustainable funding models for LTSS. Medicaid shoulders over half of all LTSS costs, but this financing is neither equitable nor sustainable. Most people will require LTSS at some point in their lifetimes, but few have the means to pay for it. One approach is for Medicare to pick up a greater share of Medicaid LTSS costs, but more fundamental reforms should be considered. For example, Washington State has moved toward a social insurance benefit for LTSS—funded through a statewide payroll tax and available to all who contribute to the benefit.
COVID-19 didn’t create the challenges facing the provision of LTSS, but it did expose them in harsh and compelling ways. With state budget cuts looming and the population aging, the system is at risk of continued deterioration—including worsening staffing shortages, less access to needed services, and even more limited oversight. COVID-19 tested the system, and despite the heroic efforts of so many, the system failed. It is up to families, policy makers and other stakeholders to seize the opportunity to make bold and lasting changes.