CMA Alert | June 10, 2021

Nursing Home Health Equity: More Evidence Showing COVID-19’s Racial Disparities

With almost 8 million people in long-term care facilities in the U.S. being either fully vaccinated or having received at least one-dose,[1] one industry group characterizes nursing facilities  as “currently the safest place to be” for older adults.[2] While deaths and cases in long-term care facilities are at an all-time low,[3] however, it remains that those facilities have accounted for over 1.4 million COVID-19 infections and almost 184,000 deaths since the pandemic began.[4]

Within those long-term care facilities, the LAist reports, Black Americans and Latinos were unduly negatively impacted. According to the article, jointly written by reporters from the LAist, The New York Times, The Baltimore Sun, and The Southern Illinoisan,

“Nursing homes where those groups make up a significant portion of the residents – no matter their location, no matter their size, no matter their government rating – have been twice as likely to get hit by the coronavirus as those where the population is overwhelmingly white.”[5]

Racial disparities in long-term care existed before the pandemic. To put the issue of disparities in context, according to the article, 80 percent of our nation’s 1.3 million nursing home residents – just over 1 million people – are white.  In nursing homes where at least 25 percent of the resident population are Black or Latino, however, more than 60 percent of those facilities reported at least one COVID-19 case, leading the journalists to conclude that “the race and ethnicity of the people living in the nursing home was a predictor of whether it was hit with COVID-19” and that the disease infected and “killed people of color at disproportionately high rates in the United States.”

The Center for Medicare Advocacy is committed to health equity and will continue to monitor and report issues on inequalities in our health care system.

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[1] Centers for Disease Control and Prevention. CDC COVID Data Tracker. (Updated June 7, 2021). Available at: https://covid.cdc.gov/covid-data-tracker/#vaccinations-ltc
[2] Mace, B. and Zahraoui, O. Nursing Homes Are Now Safe, But Data Raises Questions. (June 2, 2021). Senior Housing and Care. Available at: https://blog.nic.org/nursing-homes-are-now-safe-but-data-raises-questions
[3] Chidambaram, P. and Garfield, R. COVID-19 Long-Term Care Deaths and Cases Are at An All-Time Low, Though A Rise In LTC Cases In A Few States May Be Cause for Concern. (April 22, 2021). KFF. Available at: https://www.kff.org/coronavirus-covid-19/issue-brief/covid-19-long-term-care-deaths-and-cases-are-at-an-all-time-low-though-a-rise-in-ltc-cases-in-a-few-states-may-be-cause-for-concern/
[4] KFF, State COVID-19 Data and Policy Actions. (June 3, 2021). Available at: https://www.kff.org/coronavirus-covid-19/issue-brief/state-covid-19-data-and-policy-actions/#long-term-care-cases-deaths
[5] Gebeloff, R., Ivory, D., Richtel, M., Smith, M., Yourish, K., Dance, S., Fortiér, J., & Yu, E. The Striking Racial Divide In How COVID-19 Has Hit Nursing Homes. (June 7, 2021). LAist. Available at: https://laist.com/news/health/the-striking-racial-divide-in-how-covid-19-has-hit-nursing-homes

Report: Nursing Homes Had Highest Death Rate of All Senior Housing From COVID – Although 39% Had None

A new study by the National Opinion Research Center at the University of Chicago (NORC) analyzed the impact of COVID-19 on mortality in senior housing across the long-term care spectrum including independent living, assisted living, memory care, and skilled nursing facilities and found that mortality rates increased as the complexity of care that residents required increased.

After examining state and federal public health data in five states (Colorado, Connecticut, Florida, Georgia, and Pennsylvania), NORC estimates that 51 percent of senior housing facilities had no COVID-19 deaths in 2020. Within those facilities that did have deaths, however, death rates corresponded to “increasing levels of resident social support, health, and caregiving needs.”[1] This led to a concentration of deaths in in skilled nursing facilities, with about 60 percent having COVID-related deaths, compared to 33 percent of independent living facilities experiencing COVID mortalities.

Meanwhile, NORC found the resident deaths in independent living facilities was comparable to the death rate of older adults living in non-congregate settings in the same geographic region.  The study concludes that “health status and frailty levels of residents living in senior housing” have been a primary driver of the differences in the mortality rates during the COVID-19 pandemic.

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[1] NORC at the University of Chicago. The Impact of COVID-19 on Seniors Housing. (June 3, 2021). Available at: https://www.norc.org/Research/Projects/Pages/the-impact-of-covid-19-on-seniors-housing.aspx

United States Settles False Claims Act Case with SavaSeniorCare

The United States announced the settlement of a False Claims Act case against SavaSeniorCare, SavaSeniorCare Administrative and Consulting, and SSC Equity Holdings (Sava), originally filed by whistleblowers in four separate cases (three in Tennessee and one in Pennsylvania).[1] The settlement regards Sava billing Medicare for unnecessary rehabilitation services and for providing worthless services to residents.[2]  The privately-held Georgia-based company will pay the Federal Government $11.2 million (“plus additional amounts if certain financial contingencies occur”) and has signed a five-year chain-wide Corporate Integrity Agreement[3] with the HHS Office of Inspector General, covering 124 facilities in 12 states that are identified by name and state in Exhibit A to the Settlement.[4]

It has signed, or will sign, separate settlement agreements with certain states related to the submission of false Medicaid claims.

Medicare Billing

Between October 2008 and September 12, Sava “knowingly submitted false claims for rehabilitation therapy services as a result of a systematic effort to increase its Medicare billings.”  Through corporate-wide policies, “Sava exerted significant pressure on its SNFs to meet unrealistic financial goals, resulting in the provision of medically unreasonable, unnecessary or unskilled services to Medicare patients.”   The company “set these aggressive, prospective corporate targets for the highest Medicare reimbursement rates without regard for its patients’ actual clinical needs and then pressured its staff to meet those targets.”   The Government alleged that facilities delayed discharge of patients in order to bill Medicare.

Worthless Services

Between January 2008 and December 2018, Sava also “knowingly submitted false claims for payment to Medicare and Medicaid for grossly and materially substandard and/or worthless skilled nursing services.”  The Government alleged that Sava facilities failed to have sufficient staff, “failed to follow appropriate pressure ulcer protocols and appropriate falls protocols, and failed to appropriately administer medications to some of the residents.”

The Settlement Agreement, which is attached to the News Release, recites that in consideration of the payment and Corporate Integrity Agreement, the United States will not seek exclusion of SavaSeniorCare from the Medicare and Medicaid programs.  (Settlement ¶6.)

Corporate Integrity Agreement

The 45-page Corporate Integrity Agreement requires Sava to develop a compliance program.  An independent Monitor, to be appointed with 60 days of the settlement, will monitor the facilities’ compliance.  Sava facilities must report deaths or injuries resulting from restraints, psychotropic drugs, and abuse/neglect to the Monitor.

The Staffing Provision requires that Sava’s Compliance Committee assess and make recommendations to improve Sava’s nurse staffing.  The Committee must consult with nurse managers, facility nurses, and the Independent Monitor about staffing and must review the development and implementation of the staffing-related policies and procedures on an on-going basis to determine whether Sava facilities provide nursing staff necessary to meet residents’ needs.

Conclusion

The Corporate Integrity Agreement presents additional oversight of Sava facilities across the country.  However, additional public information about the Corporate Integrity Agreement and the 124 facilities it covers could help ensure that the Sava facilities fully comply with the Agreement and provide residents with the quality care they need.

The Center for Medicare Advocacy will try to identify the Monitor (the Inspector General does not publicly disclose the identity of Monitors) and will recommend to the Centers for Medicare & Medicaid Services that it identify, on Care Compare, the 124 facilities that are subject to the Sava Corporate Integrity Agreement.

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[1] The whistleblower cases are United States ex rel. Hayward v. SavaSeniorCare, LLC, et al., No. 3:11-cv-0821 (M.D. Tenn.); United States ex rel. Scott v. SavaSeniorCare Administrative Services, LLC, 3:15-cv-0404 (M.D. Tenn.); United States ex rel. Kukoyi v. SavaSeniorCare, LLC, et al., No. 3:15-cv-1102 (M.D. Tenn.); and United States, et al. ex rel. Thornton, et al. v. SavaSeniorCare, Inc., et al., Civil Action No. 16-CV-0840 (E.D. Pa.)
[2] United States Department of Justice, “SavaSeniorCare LLC Agrees to Pay $11.2 Million to Resolve False Claims Act Allegations; Allegations Include Medically Unnecessary Rehabilitation Therapy Services and Grossly Substandard Skilled Nursing Services” (News Release, May 21, 2021), https://www.justice.gov/opa/pr/savaseniorcare-llc-agrees-pay-112-million-resolve-false-claims-act-allegations 
[3] Sava Corporate Integrity Agreement, https://oig.hhs.gov/fraud/cia/agreements/SavaSeniorCare_LLC_and_SavaSeniorCare_Administrative_and_Consulting_LLC_052121.pdf
[4] https://www.justice.gov/opa/press-release/file/1396991/download.  Exhibit A to the Settlement identifies the 124 facilities in 12 states that are covered by the Settlement.  Sava’s website identifies 154 facilities in 18 states, https://savaseniorcare.com/find-a-center.htm

Elder Justice Newletter, Vol. 3 Issue 7 Now Available

In the Elder Justice Newsletter, we highlight citations, including deficiencies related to abuse, neglect, and substandard care, that have been identified as not causing any resident harm. The goal of this brief newsletter is to shed light on the issue of so-called “no harm” deficiencies, which typically result in no fine or penalty to the nursing home.

This newsletter focuses on the following “no harm” violations:

• ‘He did not see it as abuse’: Facility fails to appropriately address abuse allegations.
• Privacy matters: Facility fails to maintain and protect a resident’s bodily privacy.
• Six pounds down: Facility fails to assist and encourage resident with eating.
• Attempted strangulation: Facility fails to provide medically-related social services.

Do YOU think these deficiencies caused “no harm”? Click to download the newsletter.

Observation Status Bill Reintroduced

Congressman Joe Courtney (D-CT) leads a bipartisan group of Members of Congress to introduce legislation to count time spent by a patient in a hospital under outpatient “observation status” towards satisfying the three-day inpatient hospital stay prerequisite for Medicare Part A coverage of a skilled nursing facility (SNF) stay. The Improving Access to Medicare Coverage Act of 2021, H.R. 3650, seeks to end the federal policy that excludes time spent in observation status from the three-day calculation. The policy makes little sense when care received in observation status may be indistinguishable from the care received by inpatients. How hospitals bill the Medicare program for the services they provide to patients should not affect patients’ entitlement to Medicare coverage of their post-hospital care. A companion bipartisan bill will be introduced soon in the Senate.

During the coronavirus pandemic, the federal government has waived the three-day inpatient requirement for post-hospital care in a skilled nursing facility. That waiver is expected to expire with the end of the public health emergency.

An ad hoc coalition of more than 30 national groups, representing nurses, emergency room physicians, hospitalists, nursing homes, advocates for residents, and the American Medical Association, support the legislation.

The need for the legislation continues. A recent article in the Daily News-Record reports that Phoebe Orebaugh, a former longtime member of the Virginia House of Delegates and a retired educator, was hospitalized for six days in observation status, making her ineligible for Medicare Part A coverage of her subsequent SNF stay.[1] Observation status is an increasing problem for Medicare beneficiaries as the Centers for Medicare & Medicaid Services removes additional surgical procedures and services from its “inpatient only” list and authorizes these services to be classified as “outpatient”.[2]

To read the Center’s extensive materials on observation status, please go to https://medicareadvocacy.org/medicare-info/observation-status/

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[1] Ian Munro, “Medicare Changes Impacting Valley Residents,” Daily News-Record (Jun. 8, 2021), https://www.dnronline.com/news/local/medicare-changes-impacting-valley-residents/article_bac35137-f849-5a3f-accd-97d32da0ae12.html
[2] Susan Jaffe, “New cost-cutting Medicare rule may add costs to patients,” The Washington Post (Mar. 21, 2021), https://www.washingtonpost.com/health/new-cost-cutting-medicare-rule-may-add-costs-to-patients/2021/03/19/1197a3de-8747-11eb-8a8b-5cf82c3dffe4_story.html

At-Home COVID-19 Vaccinations Get a Medicare Payment Boost

The Centers for Medicare & Medicaid Services (CMS) announced an additional payment for giving in-home COVID-19 vaccinations to Medicare beneficiaries who have difficulty either leaving their homes or getting to a vaccination site. This initiative, part of President Biden’s commitment to increase access to vaccinations, could potentially affect about 1.6 million Americans 65 and older who are homebound and might have trouble accessing the COVID-19 vaccine.

“We are committed to taking action wherever barriers exist,” according to CMS Administrator Chiquita Brooks-LaSure, “and bringing the fight against the COVID-19 pandemic to the door of older adults and other individuals covered by Medicare who still need protection.”[1]

Medicare will pay an additional $35 per dose, on top of the current approximate payment of $40, bringing the total payment for COVID-19 vaccinations administered in a beneficiary’s home to about $75 per dose. For a two-dose vaccine, the total payment will be approximately $150 for both – approximately $70 more than the current rate. The additional payment also accounts for the clinical time needed to monitor the beneficiary after the vaccine is administered.

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[1] CMS. Biden Administration Continues Efforts to Increase Vaccinations By Bolstering Payments for At-Home COVID-19 Vaccinations for Medicare Beneficiaries. (June 9, 2021). Available at: https://www.cms.gov/newsroom/press-releases/biden-administration-continues-efforts-increase-vaccinations-bolstering-payments-home-covid-19

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