- CMS Long-Term Care Commission Issues Report
- Center for Medicare Advocacy Issue Brief, Examining Health Care Disparities: An Analysis of Home Health Care Received by Connecticut’s Dually Eligible Populations
- COVID 19 and Racial Disparities: Important New Analysis
- Study Finds Lower Mortality Rates in Unionized New York State Nursing Facilities
- Center for Medicare Advocacy Comments on Florida Managed Medical Assistance Waiver Request
CMS Long-Term Care Commission Issues Report
The Centers for Medicare & Medicaid Services (CMS) Coronavirus Commission for Safety and Quality in Nursing Homes, whose formation was announced in late April,[1] has issued its final report.[2] The Report identifies 27 recommendations and more than 100 action steps that are organized into 10 themes. The recommendations address testing and screening, equipment and personal protective equipment, cohorting, visitation, communication, workforce ecosystem, workforce system, technical assistance and quality improvement, facilities, and data. Eleven of the Commission’s 25 members express reservations about one or more of the recommendations. Eric Carlson of Justice in Aging dissents from the entire Report,[3] finding that it fails to address enforcement issues, facility responsibility, and alternatives to nursing facilities. CMS states that the Report validates the federal response to the coronavirus pandemic,[4] issuing a point-by-point comparison of the Commission’s recommendations and the agency’s actions.[5]
The Center for Medicare Advocacy considers the Report too generous to nursing facilities and the federal government. The Report essentially treats nursing facilities as having no responsibility for the tens of thousands of resident and staff deaths. Facilities are not blameless when research studies document that facilities with better staffing levels have fewer cases and fewer deaths;[6] when some facilities have successfully contained COVID-19 and limited its spread; and when some facilities have never had any COVID-19 cases at all.
The Report also fails to fault the lack of federal direction and accountability, both before and during the pandemic. As the Government Accountability Office reported in May 2020, the federal government has rarely imposed any penalties against facilities for their “widespread” and “persistent” failures for years before the pandemic to follow essential infection control practices.[7] Such limited enforcement signals that infection control does not matter. During the pandemic, the federal government has largely taken a hands-off approach. After waiving long-standing federal protections for residents, it left states and facilities on their own to respond to the nationwide crisis – to figure out appropriate practices, to get and require testing of residents and staff, and to get and use personal protective equipment. CMS has largely made recommendations and issued guidance, but imposed few enforceable requirements. CMS did not even require facilities to conduct essential testing of residents and staff until September 2, 2020, more than six months after the COVID-19 outbreak in a Seattle, Washington nursing facility.[8]
The report understandably focuses on the immediate issue of COVID-19, but it does not tackle the longer term changes to the nursing home system that are needed to try to prevent the tremendous suffering the pandemic has caused and could cause again in the future. Important changes going forward must include:
- Ensuring an appropriate workforce (sufficient numbers, better training, better compensation and benefits);
- Strengthening the nursing home enforcement system;
- Establishing (and enforcing), meaningful state and federal standards regarding eligibility to operate a nursing home and receive federal reimbursement; and
- Enhanced accountability for the public reimbursement that facilities receive (including enactment of a medical loss ratio to ensure that a certain specified portion of reimbursement is actually spent on resident care).
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[1] CMS, “CMS Announces Independent Commission to Address Safety and Quality in Nursing Homes” (Press Release, Apr. 30, 2020), https://www.cms.gov/files/document/coronavirus-commission-safety-and-quality-nursing-homes.pdf.
[2] Commission Final Report (Sep. 2020), https://sites.mitre.org/nhcovidcomm/wp-content/uploads/sites/14/2020/09/FINAL-REPORT-of-NH-Commission-Public-Release-Case-20-2378.pdf.
[3] Justice in Aging, “Imbalanced Commission Report Does Not Do Enough to Make Nursing Homes Responsible for Resident Safety and Quality of Life” (Sep. 2020), https://justiceinaging.org/wp-content/uploads/2020/09/Comments-on-NH-Revision.pdf?eType=EmailBlastContent&eId=ad152486-1209-4898-a7f7-4ccedc9ebed6.
[4] CMS, “Independent Nursing Home COVID-19 Commission Findings Validate Unprecedented Federal Response” (Press Release, Sep. 16, 2020), https://www.cms.gov/newsroom/press-releases/independent-nursing-home-covid-19-commission-findings-validate-unprecedented-federal-response.
[5] CMS, “Comparison: Trump Administration Actions and Commission Recommendations,” https://edit.cms.gov/files/document/covid-independent-nursing-home-covid-19-federal-response.pdf.
[6] CMA, “Studies Find Higher Nurse Staffing Levels in Nursing Facilities Are Correlated With Better Containment Of Covid-19” (CMA Alert, Aug. 13, 2020), https://medicareadvocacy.org/studies-find-higher-nurse-staffing-levels-in-nursing-facilities-are-correlated-with-better-containment-of-covid-19/; CMA, “Nursing Facilities Owned By Private Equity Firms Have Higher Rates of Covid Infections than Other Facilities” (CMA Alert, Aug. 13, 2020), https://medicareadvocacy.org/nursing-facilities-owned-by-private-equity-firms-have-higher-rates-of-covid-infections-than-other-facilities/.
[7] Government Accountability Office, Infection Control Deficiencies Were Widespread and Persistent in Nursing Homes Prior to COVID-19 Pandemic, GAO-20-576R (May 20 , 2020), https://www.gao.gov/products/GAO-20-576R.
[8] CMS, “Medicare and Medicaid Programs, Clinical Laboratory Amendments (CLIA), and Patient Protection and Affordable Care Act; Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency,” CMS-3401-IFC, 85 Fed. Reg. 54,820 (Sep. 2, 2020), https://www.govinfo.gov/content/pkg/FR-2020-09-02/pdf/2020-19150.pdf.
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The Center for Medicare Advocacy recently released an Issue Brief, Examining Health Care Disparities: An Analysis of Home Health Care Received by Connecticut’s Dually Eligible Population. With support from the Connecticut Health Foundation and assistance from a University of Connecticut professor, the Center reviewed and analyzed Medicaid paid home health services for dually eligible people in Connecticut to identify disparities in the receipt of care within the dually eligible population. The Issue Brief discusses our analysis, findings, and recommendations for possible interventions that might lead to improved access to necessary health care. The analysis considered data regarding race, ethnicity, diagnosis, and geographic location.
Read the full Issue Brief at https://medicareadvocacy.org/wp-content/uploads/2020/09/CT-Health-Foundation-Disparity-Report-Final.pdf
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COVID 19 and Racial Disparities: Important New Analysis
Kaiser Family Foundation released analysis this week regarding racial disparities during the COVID-19 crisis, by examining testing, infection, hospitalization, and death by race and ethnicity among patients in the Epic health record system. The Center for Medicare Advocacy (the Center), continues to highlight COVID-19 data and resources showing the correlation between low incomes, communities of color, and risks of illness and severity of illness, for and following infection with COVID-19. The Center aims to call attention to the ongoing, harmful health disparities exposed by the pandemic.
Key findings from the report COVID-19 Racial Disparities in Testing, Infection, Hospitalization, and Death: Analysis of Epic Patient Data include:
- People of color were more likely, compared to White patients, to be positive when tested and to require a higher level of care at the time they tested positive for COVID-19.
- Hispanic patients were over two and a half times more likely to have a positive result (311 per 1,000) and Black and Asian patients were nearly twice as likely to test positive (219 and 220 per 1,000, respectively) compared to White patients (113 per 1,000).
- Larger shares of Black, Hispanic, and Asian patients were in an inpatient setting when they tested positive for COVID-19 compared to White patients, and they also were more likely to require oxygen or ventilation at the time of diagnosis.
- Black, Hispanic, and Asian patients had significantly higher rates of infection, hospitalization, and death compared to their White counterparts.
- Racial disparities in hospitalization and death persisted among positive patients even after controlling for certain sociodemographic factors and underlying differences in health, with Asian patients exhibiting the highest relative risk.
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Study Finds Lower Mortality Rates in Unionized New York State Nursing Facilities
An analysis of nursing facilities in New York State finds that, compared to facilities without labor unions, facilities with unions had:
- A 30% lower morality rate from COVID-19
- A 42% “relative decrease in COVID-19 infection rates” among residents
- Greater access to certain types of personal protective equipment
- A 13.8% “relative increase in access to N95 masks”
- A 7.3% “relative increase in access to eye shield”
Adam Dean, Atheendar Verkataramani, and Simeon Kimmel, “Mortality Rates From COVID-19 Are Lower In Unionized Nursing Homes,” Health Affairs (published Sep. 10, 2020).
The analysis was based on 355 (of 621) nursing facilities in New York State that had confirmed data on COVID-19 mortality for the period March 1 through May 31, 2020. Health care unions were present in 246 of the 355 nursing facilities that were included in the analysis. Researchers included residents who died of COVID-19 inside nursing facilities, not residents who died following discharge to a hospital.
The researchers described “Unionized facilities . . . [as] more likely to be for-profit, less likely to be associated with a chain, had lower LPN-to-resident ratios, and were located in more populous counties with higher per capita rates of confirmed COVID-19 cases.” The finding that better resident outcomes occurred in nursing facilities that were located in counties with higher rates of COVID-19 counters the nursing home industry’s argument that the “most important” factor determining COVID-19 is zip code.
Please go to: “Mortality Rates From COVID-19 Are Lower In Unionized Nursing Homes,” available at https://www.healthaffairs.org/doi/10.1377/hlthaff.2020.01011.
American Health Care Association, “We Won’t Back Down” (Jun. 2020) https://files.constantcontact.com/64f0b60b701/f86b03a3-a859-4098-b6d0-3866c56672d5.pdf , discussed in “American Health Care Association’s CEO Issues Message to Members: ‘We Won’t Back Down,’” (CMA Alert, Jul. 16, 2020), https://medicareadvocacy.org/american-health-care-associations-ceo-issues-message-to-members-we-wont-back-down/.
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Center Comments on Florida Managed Medical Assistance Waiver Request
The Center for Medicare Advocacy submitted joint comments with the Florida Health Justice Project (FHJP) to the Centers for Medicare and Medicaid Services (CMS) regarding Florida’s application to the CMS seeking a two-year extension of the 1115 Managed Medical Assistance (MMA) Waiver. Our comments focused on the repeal of Retroactive Medicaid Eligibility (RME) and the continuation of the Low Income Pool (LIP).
The joint comments are available in full here: https://medicareadvocacy.org/wp-content/uploads/2020/09/FL1115-Comments-PDF-Final.pdf
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