by Dan Osterweil, MD, FACP, CMD

The phenomenon of prescribing rehab services to some nursing home residents towards the end of their life was highlighted in a paper published in JAMDA and got wide citations in the New York Times and other publications. It was a courageous stance to shine a spotlight on the fact that between 2012-2016 NH’s in the State of New York were observed to provide rehab services in greater quantity to nursing home residents in their last month of life. While this data comes from one state, they resonated with data from CMS indicating a steep increase in the number of nursing home residents receiving high intensity of rehab services (at least 325 min/week) in the last month of life. This was almost a two-fold increase in this phenomenon in for-profit facilities compared to non-profit facilities.  While the authors and commentators focus on the economics and appropriateness of this phenomenon, it also indicates to a flaw in the way CMS pays for services in the nursing home. While some of the services seem excessive and inappropriate, they may point to need to find a way to be able to care for these patients who have functional and medical problems in post-acute care. The current reimbursement scheme does not recognize non-curative or non-rehabilitative services as eligible for SNF coverage, thus putting a huge burden on families who care for those complex patients who may be nearing the end of life and are not good rehabilitation candidates.

While gaming the system should not be condoned, this indicates a need for an immediate change in how CMS is paying for the care of this growing number of Americans. This paper also points to the fact that the facilities with higher number of licensed staff (LVN and RN) provided more appropriate care to these patients and utilized less high-intensity rehab services. Presumably, this might indicate that they are providing appropriate palliative care instead (although this was not specifically documented in the study).  This finding supports the findings of many studies by Schnelle, Ouslander, Jensen and Simmons, with whom I had the privilege to collaborate with while working at the Borun Center for gerontological research. A study by this group funded by CMS and kept on the shelf for almost a decade, pointed out that a NH needs a minimum of 2.5 hours of licensed staff and overall 4.2 hours per NH resident per day to carry out the care mandated by CMS regulations.

This points to the flip side of the problem, underfunding of post-acute services leaving operators to create their own methods to increase funding. While these methods may constitute abuse of the system and should not be condoned this should be a call to action for all of us. As prescribers we should adhere to the highest clinical and ethical standards. NH’s should also impose better checks and balances on their teams’ practices. CMS and legislators should stop the charade of paying acute hospitals through the roof while underfunding post-acute and chronic long-term care services. It will be interesting to see how much CMS’s proposed new per-diem payment system called the Patient-Driven Payment Model (PDPM) will address some of these inequities.

Click here for referenced article:  https://www.bloomberg.com/amp/news/articles/2018-10-09/nursing-homes-are-pushing-the-dying-into-pricey-rehab

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