Oct 10, 2018

Systemic Medicare Fraud in the Nursing Home Industry

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A new study contends that nursing homes may be pushing dying patients into unnecessary and potentially harmful high-intensity rehab services. University of Rochester Medical Center researchers noted that the number of residents receiving “ultra-high” rehab services in New York state increased by 65% during the three-year period ending in 2015. Most of those services were delivered to individuals in the last seven days of their lives, according to the analysis of data from 647 nursing homes in the Empire State that was published week in the Journal of the American Medical Directors Association.

“These are often sick and frail patients in whom the risks of intensive levels of rehabilitation actually outweigh the benefits,” Thomas Caprio, M.D, a geriatrician and hospice physician at URMC and co-author of the study, said in a statement. “It can increase the burden of pain and exhaustion experienced by patients and contribute to their suffering.”

Researchers honed in on residents in the Very High (520 minutes per week) to Ultra-High (720 minutes) groupings of rehab services in the last 30 days of life.


The new study raises questions about the use of high-intensity therapy minutes at the end of residents’ lives.  Between 2012 and 2016, ultra-high rehabilitation services provided to nursing home residents in their final month of life spiked 65%, according to research from the University of Rochester, with overall end-of-life therapy use rising 20%. In addition, residents of for-profit nursing homes were almost twice as likely to receive high- to ultra-high therapy than those in non-profit buildings.

Those findings mirror trends identified by the Department of Health and Human Services Office of the Inspector General (OIG), lead researcher Helena Temkin-Greener told Skilled Nursing News.

The OIG found that between 2011 and 2013, the overall proportion of ultra-high therapy minutes grew from 49% to 57%, raising general concerns about the necessity of such services. Writing in the study, published in the October issue of JAMDA — The Journal of Post-Acute and Long-Term Care Medicine, Temkin-Greener and her colleagues noted that the OIG identified a hospice resident who asked to stop receiving therapy — but continued to receive physical therapy services five days per week for more than a month.

 “They don’t seem to be associated with changes in resident characteristics,” Temkin-Greener, a professor emeritus at the University of Rochester’s Department of Public Health Services, said. “So the residents’ care needs appear to stay the same over a period of time, but [there are] increases in the use of ultra-high therapy.”

Temkin-Greener specifically cited the gap between for-profit and non-profit nursing home therapy as a reason for concern.

“That gives me pause. If receiving high- to ultra-high therapy is a good thing at the end of life, then I shouldn’t be seeing such a significant finding, with two-fold higher odds of receiving it in nursing homes associated by profit status,” she said. “If it’s good for everybody, everybody should get it. If it’s bad for everybody, nobody should get it. I’m sure there are shades in between, but I shouldn’t be seeing profit status as an indicator.”

Based on those results, the team concluded that financial pressures may frequently play a role in the therapy decision-making process at nursing homes.  CMS specifically cited the potential for abuse under the old system as a key driver of the payment overhaul.

“When a nursing home has more RNs per resident per day, the use of ultra-high therapy decreases at the end of life,” she said. “So that suggests that higher skill allows people to recognize that a patient is dying, actively dying, and not provide ultra-high therapy.”

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