At this moment, nursing home staff and residents across the country are receiving the COVID-19 vaccine. While there is much to celebrate in the beginning of the end of a tragic chapter in our nation’s history, COVID-19 has exposed significant deficiencies in the nation’s long-term care system that policymakers can no longer ignore. Our country needs a new vision for elder care, one that provides more options for seniors and achieves a higher level of safety and quality in nursing homes.
Despite nursing homes receiving infection control guidance, government-funded testing, training, supplies, staffing and over $7 billion in additional funding, far too many residents have tragically lost their lives. Keeping nursing home residents safe despite community spread has proven a lasting challenge. Such struggles did not materialize out of thin air; long before COVID-19 struck, infection control was the most commonly cited infraction in nursing home surveys.
Our long-term care system relies too heavily on nursing homes, which are seen as the default option even for those who may not require round-the-clock care. Nursing homes are a vital and necessary part of America’s elder-care system, but our first goal should be to help our aging loved ones preserve their dignity by providing support in home- or community-based settings, which can be more cost effective and preferred by seniors.
However, these services face a variety of barriers, including reimbursement rates, workforce challenges and coverage limitations for home-based services. These barriers have limited offerings of such care throughout the country.
CMS has made a number of changes that provide Medicare beneficiaries more options. For example, plans in Medicare Advantage (the privately administered branch of the program) have more flexibility to provide benefits such as meal delivery, transportation and home modifications that keep seniors healthy and independent.
Nevertheless, nursing home care will always be an important option for people who need a higher level of care, and there is much work to be done to increase quality and safety. Nursing homes face a precarious financial situation and the pandemic has exacerbated it. Medicaid is the largest payer of long-term care but its reimbursement rates are often low, resulting in razor-thin or negative margins that make staffing and training difficult. All our regulation and oversight is for naught if nursing homes lack the resources to hire competent staff and implement best practices.
But the answer isn’t more taxpayer funding. Rather, we must fix how we pay for care. Currently, only about 2 percent of nursing homes’ Medicare reimbursement is tied to quality outcomes. While congressional action allowing CMS to add additional quality measures will go a long way toward incentivizing better performance, Medicaid programs continue to reimburse nursing homes on an ineffective per-day basis, regardless of outcomes. Today, a one-star home is paid the same rate as a five-star home. It’s time we start paying nursing homes based on what matters to residents and families: health outcomes as measured by safety and quality of life.
The thicket of regulations surrounding nursing homes has not prevented countless quality concerns. We inherited a regulatory quagmire finalized in the waning days of the Obama administration. These process-focused—rather than more effective outcome-focused—requirements dictate virtually every aspect of nursing homes’ operations. Clearly, they failed to protect nursing home residents from COVID-19.
Outcome-focused payment must be paired with outcome-focused regulations. Facilities certainly must be held accountable. They, after all, are ultimately responsible for a resident’s care, but they should be held accountable for the right things; the level of infectious disease in a home is a better measure than the number of months a facility keeps paperwork on file. Regulation must move beyond process and focus on the outcomes we want nursing homes to achieve.
Today’s antiquated regulatory regime was designed more than a quarter century ago. It makes for a complex and onerous system of survey and enforcement that is geared toward financial penalties but fails to improve quality or resolve problems. While annual surveys are important, they mostly focus on checking compliance with meaningless process requirements. CMS is already moving toward using advanced analytics to analyze data from a variety of sources, such as quality data, survey reports, claims data and data from the CDC, to proactively identify poorly performing nursing homes and work with them to overcome their challenges.
Coronavirus has had a shattering impact on nursing homes and my heart goes out to all residents, families and frontline health care staff who have endured loss and isolation. We owe it to those who have suffered to make the devastation they experienced last year be the catalyst for change.
Seema Verma is Administrator, Centers for Medicare and Medicaid Services.
The views expressed in this article are the writer’s own.