[Senate Hearing 117-280]
[From the U.S. Government Publishing Office]
S. Hrg. 117-280
A NATIONAL TRAGEDY: COVID-19
IN THE NATION'S NURSING HOMES
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HEARING
BEFORE THE
COMMITTEE ON FINANCE
UNITED STATES SENATE
ONE HUNDRED SEVENTEENTH CONGRESS
FIRST SESSION
__________
MARCH 17, 2021
__________
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]
Printed for the use of the Committee on Finance
__________
U.S. GOVERNMENT PUBLISHING OFFICE
47-758 PDF WASHINGTON : 2022
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COMMITTEE ON FINANCE
RON WYDEN, Oregon, Chairman
DEBBIE STABENOW, Michigan MIKE CRAPO, Idaho
MARIA CANTWELL, Washington CHUCK GRASSLEY, Iowa
ROBERT MENENDEZ, New Jersey JOHN CORNYN, Texas
THOMAS R. CARPER, Delaware JOHN THUNE, South Dakota
BENJAMIN L. CARDIN, Maryland RICHARD BURR, North Carolina
SHERROD BROWN, Ohio ROB PORTMAN, Ohio
MICHAEL F. BENNET, Colorado PATRICK J. TOOMEY, Pennsylvania
ROBERT P. CASEY, Jr., Pennsylvania TIM SCOTT, South Carolina
MARK R. WARNER, Virginia BILL CASSIDY, Louisiana
SHELDON WHITEHOUSE, Rhode Island JAMES LANKFORD, Oklahoma
MAGGIE HASSAN, New Hampshire STEVE DAINES, Montana
CATHERINE CORTEZ MASTO, Nevada TODD YOUNG, Indiana
ELIZABETH WARREN, Massachusetts BEN SASSE, Nebraska
JOHN BARRASSO, Wyoming
Joshua Sheinkman, Staff Director
Gregg Richard, Republican Staff Director
(ii)
C O N T E N T S
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OPENING STATEMENTS
Page
Wyden, Hon. Ron, a U.S. Senator from Oregon, chairman, Committee
on Finance..................................................... 1
Crapo, Hon. Mike, a U.S. Senator from Idaho...................... 3
WITNESSES
Ramos, Adelina, Certified Nursing Assistant, SEIU District 1199
New England, Greenville, RI.................................... 6
Bottcher, Denise, State director, AARP Louisiana, Baton Rouge, LA 7
Moten, Quiteka, MPH, CDP, State Long-Term Care Ombudsman,
Commission on Aging and Disability, State of Tennessee,
Nashville, TN.................................................. 9
Konetzka, R. Tamara, Ph.D., Louis Block professor, Department of
Public Health Sciences, Biological Sciences Division,
University of Chicago, Chicago, IL............................. 11
Dicken, John E., Director, Health Care, Government Accountability
Office, Washington, DC......................................... 13
Gifford, David, M.D., MPH, chief medical officer, American Health
Care Association/National Center for Assisted Living,
Washington, DC................................................. 14
ALPHABETICAL LISTING AND APPENDIX MATERIAL
Bottcher, Denise:
Testimony.................................................... 7
Prepared statement........................................... 53
Responses to questions from committee members................ 56
Brown, Hon. Sherrod:
Submissions for the record................................... 61
Crapo, Hon. Mike:
Opening statement............................................ 3
Prepared statement........................................... 132
Dicken, John E.:
Testimony.................................................... 13
Prepared statement........................................... 133
Responses to questions from committee members................ 143
Gifford, David, M.D., MPH:
Testimony.................................................... 14
Prepared statement........................................... 155
Responses to questions from committee members................ 163
Konetzka, R. Tamara, Ph.D.:
Testimony.................................................... 11
Prepared statement........................................... 175
Responses to questions from committee members................ 180
Moten, Quiteka, MPH, CDP:
Testimony.................................................... 9
Prepared statement........................................... 188
Responses to questions from committee members................ 190
Ramos, Adelina:
Testimony.................................................... 6
Prepared statement........................................... 193
Responses to questions from committee members................ 195
Scott, Hon. Tim:
Prepared statement........................................... 197
Wyden, Hon. Ron:
Opening statement............................................ 1
Prepared statement........................................... 198
Communications
Alzheimer's Association and Alzheimer's Impact Movement.......... 201
American Geriatrics Society...................................... 203
Arbeeny, Dan..................................................... 206
Carter, Marla.................................................... 209
Caspi, Eilon, Ph.D............................................... 214
Center for Fiscal Equity......................................... 215
Center for Medicare Advocacy..................................... 218
Hamilton, Elizabeth.............................................. 224
Holland, Tamra................................................... 225
Hull, Gay L...................................................... 227
James, Kathy..................................................... 227
Justice in Aging................................................. 228
Landry, Lydia Nunez.............................................. 231
LeadingAge....................................................... 236
Leljedal, Carrie................................................. 240
Mimbs, Ja'Nisa................................................... 242
National Consumer Voice for Quality Long-Term Care et al......... 243
Nichols, Mary.................................................... 252
Oregon Health and Science University............................. 254
Piper, Carolyn................................................... 255
Premier Inc...................................................... 258
Rister, Beth..................................................... 262
Toscano, Nora.................................................... 263
Wasserman, Michael R., M.D., CMD................................. 266
Winters, Rachel.................................................. 273
A NATIONAL TRAGEDY: COVID-19
IN THE NATION'S NURSING HOMES
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WEDNESDAY, MARCH 17, 2021
U.S. Senate,
Committee on Finance,
Washington, DC.
The hearing was convened, pursuant to notice, at 10 a.m.,
via Webex, in the Dirksen Senate Office Building, Hon. Ron
Wyden (chairman of the committee) presiding.
Present: Senators Stabenow, Cantwell, Menendez, Cardin,
Brown, Bennet, Casey, Warner, Whitehouse, Hassan, Cortez Masto,
Crapo, Grassley, Thune, Portman, Toomey, Cassidy, Lankford,
Daines, Young, and Barrasso.
Also present: Democratic staff: Peter Gartrell,
Investigator; Kristen Lunde, Health Policy Advisor; and Joshua
Sheinkman, Staff Director. Republican staff: Gregg Richard,
Staff Director; Erin Dempsey, Deputy Health Policy Director;
and Stuart Portman, Senior Health Policy Advisor.
OPENING STATEMENT OF HON. RON WYDEN, A U.S. SENATOR FROM
OREGON, CHAIRMAN, COMMITTEE ON FINANCE
The Chairman. This morning, the Finance Committee is
holding the second of three hearings that we will be holding
this week. And this is a particularly important hearing,
because our country is now a full year into the COVID-19
pandemic.
And let me just give a brief kind of process statement with
respect to how we are going to do this. We have two votes at
11:30, and we are going to do everything we can to keep this
moving. We have been working with the ranking member, Senator
Crapo, on this. And if we do not do that, we will probably be
here until 3 o'clock. So we are going to do our best to keep
this moving.
As I indicated, we are a year in, and vaccinations are up.
Americans are beginning to feel encouraged, and yet so many
families--hundreds of thousands spread across the country--are
unable to share in the sense of uplift because they are
mourning loved ones whom they have lost.
Over the last year, more than 175,000 long-term care
residents and workers, including 130,000 living and working in
federally certified nursing homes, have died of this terrible
disease. They were at the center of a collision of
mismanagement. In too many nursing homes--even before the
pandemic--there was chronic under-
staffing, slipshod plans for infection control, and abuse and
neglect of vulnerable patients.
When COVID-19 arrived, the Trump administration came up
small by withholding data, failing to distribute protective
equipment, and issuing guidance that put seniors in harm's way.
This was a systemic, nationwide failure, and it will be
challenging to fix. Members can start by agreeing on basic
facts.
First, what is true of the overall population is true in
our nursing homes. Blacks, Latinos, and Native Americans are
suffering the worst of COVID-19. A recent study authored by
Professor Konetzka, one of the witnesses joining the committee,
found that the loss of life was more than three times higher in
nursing homes with the highest proportions of black and Latino
residents compared to facilities with mostly white residents.
Black Americans and immigrants also make up a
disproportionate share of nursing home staff. Often, they get
paid low wages. More than half a million of them have had
confirmed cases of COVID-19, and thousands have died. There is
also real concern that COVID-19 will continue to circulate
among those communities where vaccines are not readily
available, or where uptake is lower.
These disparities in COVID-19 deaths are the result of
generations of inequity in society and in health care. Undoing
it is going to take a lot of work by this committee, and I know
colleagues feel very strongly about getting it done.
Second, the previous administration actively impeded
efforts to address long-running problems in nursing homes. You
could fill a library with the watchdog reports calling public
attention to these issues: incidents of abuse and neglect,
chronic under-staffing, horrendous living conditions,
inadequate emergency preparedness. This was an industry-wide
failure also when it came to inspection control.
Instead of addressing these questions, the Trump
administration dramatically reduced the penalties for failing
to meet basic protective Federal standards. They went out of
their way to undermine a chance for real accountability. When
States rushed to develop COVID policies, some followed Trump
administration guidance that encouraged nursing homes to accept
patients regardless of whether they had tested positive for the
virus.
When the pandemic was spreading and nursing homes
desperately needed PPE, the Trump administration sent out
shipments that reportedly included loose, unusable gloves,
hospital gowns that resembled trash bags, and defective masks.
The Trump administration did not want people to know about
what was going on in nursing homes. Our colleague, Senator
Casey, and I spent months pressuring and pleading with them to
release comprehensive data. The Trump administration
stonewalled. They dithered, and they delayed before they
finally began to relent. As of now, there still is no reliable
data on COVID in nursing homes before May 1st of last year
because of the Trump administration's stonewalling.
One final point. The terrible impact of COVID-19 on seniors
in long-term care is not a red State or a blue State issue. It
is a nationwide tragedy. Specifically, if you look at the 10
States where nursing homes have been hit the hardest, it is
five Republican-led States and five Democratic-led States.
So the reality is, long-term care residents in all 50
States are incredibly vulnerable to a pandemic like COVID-19
for longstanding reasons, but the Trump administration worked
harder to protect their unscrupulous friends in management than
to improve the safety of residents.
The Biden administration is working to turn things around.
It starts with ramping up vaccinations and creating strike
teams of highly trained workers who will go into nursing homes
and identify the safety risks.
This hearing is not the first or the last time the
committee is going to be digging into nursing home safety. We
are going to continue to work with members, all members of this
committee, because looking after the well-being of America's
seniors is at the heart of our jurisdiction.
Personally, I feel strongly about this after my 7 years as
co-
director of the Oregon Gray Panthers, and I look forward to
working with colleagues on both sides of the aisle.
We will start with our panelists, and an introduction,
right after Senator Crapo's opening statement.
[The prepared statement of Chairman Wyden appears in the
appendix.]
OPENING STATEMENT OF HON. MIKE CRAPO,
A U.S. SENATOR FROM IDAHO
Senator Crapo. Thank you, Mr. Chairman.
At the national, State, and local levels the pandemic has
challenged our sense of normalcy. It has tested every
institution of daily life we know, threatening the physical and
economic health of our Nation.
Americans from all walks of life have experienced a full
year of tremendous hardship and tragedy. It is the people
living and working in our Nation's nursing homes, however, who
bore an outsized burden.
More than 174,000 people died as COVID-19 ravaged our long-
term care facilities. That number represents almost one-third
of all U.S. deaths that have occurred during the pandemic.
Both long-stay nursing homes and short-stay post-acute
skilled nursing facilities rely on direct-care workers--such as
licensed practical nurses, Certified Nursing Assistants, and
personal care aides--to provide most hands-on care.
These workers are in close physical contact with residents,
assisting with bathing, dressing, and eating. Current data
shows that long-term care workers are typically female, and a
disproportionate share are women of color. Many of these
direct-care workers live paycheck to paycheck. Over the past
year, they have put their lives on the line. We owe them a debt
of gratitude. Thank you to the dedicated nursing home workers
like Adelina Ramos, one of our witnesses.
These workers hear Americans calling them heroes, but they
are often under-appreciated when on the job. To these front-
line workers, please know that the sacrifices you are making
every day do not go unnoticed or unappreciated.
Today we will hear from a number of expert witnesses who
will provide key insights into nursing home conditions over the
past year. This testimony will help us better understand
exactly what happened, when it happened, and why it happened.
It will give us insight into policies that produce results, as
well as areas that need improvement.
Hearings are just oversight tools this committee uses to
hold government agencies, the health-care industry, and
individual providers accountable. Another key part of oversight
is securing reliable and accurate data.
Transparent data reporting brings accountability and helps
drive decision-making. Transparent data reporting brings
tremendous support to the system. As we look to the future, it
is vital that all States report accurate COVID-19 data. That is
the only way for economists, researchers, advocacy
organizations, and policy-makers to tackle the challenges
facing the nursing home sector head-on.
This is not a job for the Federal Government alone.
Multiple Federal, State, and local programs and partnerships
work to support the health-care needs of our Nation's most
vulnerable populations. We must work together--in an honest and
transparent manner--to safeguard our nursing home residents and
the workers who care for them.
Over the weekend, The New York Times published the results
of an investigation into the Centers for Medicare and Medicaid
Services' nursing home five-star rating system. The
investigation questions the objectivity and accuracy of the CMS
star ratings system.
This rating system, which was first implemented during the
Obama administration, is designed to help beneficiaries, their
families, and caregivers compare nursing home quality more
easily.
Care Compare is another online tool available to help
seniors, the disabled, and their families find out if a
particular nursing home facility meets Federal health and
safety standards, staffing levels, and quality performance
metrics.
After several bipartisan hearings held by the Finance
Committee during 2019, CMS implemented changes to Nursing Home
Compare that specifically denote nursing homes that have been
cited for incidents of abuse, neglect, or exploitation.
That may have been a start, but clearly there is a lot more
work that needs to be done. I am grateful to each of our
witnesses for the work they are doing, and for taking the time
to join us today. Their expertise will help us advance public
policies that slow the spread of COVID-19 and lessen its
devastating impacts on our Nation's elderly and the disabled.
And, Mr. Chairman, before I conclude, Senator Scott will
not be able to make his statement, or be participating today,
but he is one of the leaders in our Senate on trying to deal
with and address this issue properly. And he has asked that I
request a statement of his be entered into the record.
I ask unanimous consent that his statement be entered into
the record.
The Chairman. Without objection, so ordered.
[The prepared statement of Senator Scott appears in the
appendix.]
Senator Crapo. Thank you very much, Mr. Chairman.
[The prepared statement of Senator Crapo appears in the
appendix.]
The Chairman. Okay. We are now going to go to our panel.
Senator Whitehouse has requested to introduce Ms. Ramos. We are
very glad that you could be here and have known of your efforts
for quite some time, Ms. Ramos. So we are glad you are here.
Senator Whitehouse?
Senator Whitehouse. Thank you, Mr. Chairman.
Rhode Island lost more than 1,000 nursing home residents to
COVID. Nationwide, as Senator Crapo pointed out, there have
been more than 174,000 nursing home residents and caretakers
who have died.
Nearly a quarter of Rhode Island's nursing homes reported
shortages of nurses and nursing aides during the pandemic. So I
am very pleased and grateful that the committee will be hearing
from Rhode Islander Adelina Ramos today.
She lived this crisis as a Certified Nursing Assistant at
the Greenville Nursing Center in Greenville, RI. She is a proud
SEIU member, and I am grateful to her and to her union.
From late April to Memorial Day, Ms. Ramos witnessed 20
residents at her 160-bed facility perish. She watched a
colleague die. In one harrowing moment, she and a team of just
three staffers cared for over two dozen critically ill COVID
patients.
Eventually, she caught the virus herself, and feared
spreading it to her family, for whom she also provides care at
home. At last, Ms. Ramos is fully vaccinated and hopeful for
the future.
Senator Casey and I worked to provide our nursing homes
emergency funding for staffing and testing and PPE, and for
nursing home strike teams to boost capacity at facilities in
need. We finally got much of this support into the American
Rescue Plan, but it had been blocked in all the previous COVID
bills.
It would have served Adelina and her colleagues better if
we had done this earlier, but at least we got it done at last.
So I am pleased to welcome Ms. Ramos here to our committee.
Thank you, Mr. Chairman, and thank you, Ranking Member.
The Chairman. Thank you very much, Senator Whitehouse. At
this point, I am just going to give brief introductions for our
other guests.
Denise Bottcher is here. She is a State director of AARP in
Louisiana. She has worked for AARP since 2010, and previously
was with Governor Kathleen Blanco.
Then we will have a very important presentation from a
Long-Term Care Ombudsman, Quiteka Moten. She is from Tennessee.
She is based in Nashville. She works with the Alzheimer's
Association now, establishing rural senior networks, training
first responders, and managing early-stage engagement programs.
And then Tamara Konetzka, Louis Block professor of public
health in the Department of Public Health Sciences at the
University of Chicago. She serves on a number of Federal
boards. She received her Ph.D. from the University of North
Carolina. We are very glad to have her because we have seen her
renowned scholarship, and we look forward to her presentation.
So, let's begin with Ms. Ramos.
STATEMENT OF ADELINA RAMOS, CERTIFIED NURSING ASSISTANT, SEIU
DISTRICT 1199 NEW ENGLAND, GREENVILLE, RI
Ms. Ramos. Thank you, Mr. Chairman, Ranking Member Crapo,
and the members of the Senate community. My name is Adelina
Ramos. I am a CNA at a nursing home in Greenville, RI. I am a
proud immigrant from the Cape Verde Islands off the western
coast of Africa.
At my facility, I work with Alzheimer's patients. To be
trusted by families to care for their loved ones is a great
honor. But over the past year, my days have been filled with
fear and sadness.
I do not think anyone in my small community thought that
COVID-19 would arrive at our doorstep. But it did, and nursing
homes were not prepared. When COVID first hit, we lost over 20
residents in just over a month--and a CNA died too.
We confronted management to let them know we did not have
enough PPE or enough training to keep our residents safe and to
prevent the virus from spreading in our facility.
We are extremely short-staffed too. At one point, I was
caring for 26 critically ill residents with the help of only
one other CNA, a nurse, and a housekeeper. They could not eat,
drink, or move by themselves. Some of them required oxygen
changes every 15 minutes. And because they had Alzheimer's,
sometimes they would get scared.
I was horrified. We begged management for more staff on
each shift, but they said they could not find anyone. And so
our residents and staff kept getting sick and dying.
The day after Mother's Day, I realized I could not smell my
ginger tea. I thought it was because of my mask. But a few
weeks later, I got symptoms and I had COVID. I did not have
other symptoms, so I did not know, and I put those around me at
risk. I never thought I would have to tell my son to stay away
from me, don't touch me, don't hug me, don't get too close. I
would never be able to forgive myself if I infected him, so I
did what I had to do to keep him safe.
Today, I am COVID-free and vaccinated, and I am holding my
family close. And I am working to educate others about how
important it is to get vaccinated. Things are looking up, but
the physical and emotional trauma this pandemic caused cannot
be cured with a shot in the arm.
When I started working at a nursing home, I understood I
would have residents pass away. In their final moments, our job
is to make sure they are comfortable, cared for, and surrounded
by loved ones. The family members could not come into our
facility. The funeral homes could not come either, because they
did not have enough PPE. So we became the mortician and had to
put bodies into body bags.
My residents deserved so much better than what we were able
to provide them, with few staff and resources. As they took
their final, difficult breath, I hope they knew that we tried
our best.
The starting wage for Rhode Island nursing home workers is
just $12.34. Some of us have to work multiple jobs to meet our
basic needs. Because of these actions, we do not have time to
spend with the residents when they need us.
My worst day during COVID was when one of my residents was
dying and wanted me to sit and hold her hand, but I could not
stay because I had 20-plus other residents who also needed me.
I feel a calling to do this job and care for others, but
passion cannot pay bills. I am fortunate that I am a member of
my union, SEIU 1199 New England. We negotiated higher wages and
pandemic pay. We were able to advocate for ourselves and
residents, but not every nursing home worker has a union.
This issue existed before COVID. COVID-19 just exposed the
most tragic and deadly part of nursing home work. It is why I
keep fighting for a $15 minimum wage in the union for all
workers.
This pandemic has shown us what happens when we are not
prepared to meet the demands for care. We must build back
better so that when the time comes when your loved one needs
care--and that time will come for all of us--someone like me
will be there to answer your call.
[The prepared statement of Ms. Ramos appears in the
appendix.]
The Chairman. Ms. Ramos, thank you. And we wanted you to
speak first because we felt that you could really give us a
sense of what this was like on the floor where patients lived,
and the challenge. And we knew you were going to give us an
important presentation. And thank you, thank you, thank you,
because you are speaking for so many this morning.
Our next speaker will be Denise Bottcher, and, let's see,
there is Ms. Bottcher. Please proceed.
STATEMENT OF DENISE BOTTCHER, STATE DIRECTOR,
AARP LOUISIANA, BATON ROUGE, LA
Ms. Bottcher. Good morning, Chairman Wyden, Ranking Member
Crapo, and members of the committee. My name is Denise
Bottcher, and I am State director for AARP of Louisiana. On
behalf of our 38 million members--including over 425,000 in
Louisiana--and all older Americans nationwide, AARP appreciates
the opportunity to provide testimony at today's hearing.
The situation in our Nation's nursing homes and other long-
term care facilities has been alarming since the first COVID
outbreak in Washington State. AARP has heard from thousands of
people who have lost loved ones, and that is why, across the
Nation, AARP has advocated for the health, safety, and well-
being of residents and staff.
As has been mentioned, over 175,000 long-term care facility
residents and staff have died. And that includes almost 3,000
in Louisiana. This represents about 35 percent of deaths
nationwide. While there may be a sense of relief with vaccines
rolling out and infection rates declining, much more is needed
to protect nursing home residents.
The consequence of not acting is that someone's mother or
father dies. One resounding message I have received from
families across Louisiana is this: if 175,000 deaths does not
inspire bold action, then nothing will.
AARP has urged action in a five-point plan to protect the
health and safety of residents.
First, ensure facilities have adequate personal protective
equipment for everyone at the facility, and ensure its
consistent and proper use, as well as prioritizing testing.
Yesterday I had the opportunity to visit with Mark Ferguson
in Lake Charles, LA. His 86-year-old dad and 63-year-old
brother lived in the same nursing home. And every week he
visited with his dad and brother through a window. And each
time, he observed staff not wearing masks or gloves.
He told me he felt helpless in this moment because it was a
matter of life and death. The only thing he could do was call
and report it to the administrator. The following week, he
would again visit, and the staff were not properly wearing PPE.
He eventually lost his dad to COVID, and he still fights this
battle today.
I asked him what keeps him up at night, and he told me the
health and safety of his brother Scott. It is unacceptable for
facilities to have PPE shortages a year into the pandemic.
AARP's second point: continue to improve transparency. We
believe care facilities should publicly report cases and deaths
daily, rather than weekly. That reporting should include
demographic data such as race and ethnicity.
Information about the number and percentage of residents
and staff who have been vaccinated should be available by
facility and State. We urge the Federal Government to work with
States and long-term care facilities to ensure they can access
and administer vaccines to new residents and staff as needed.
Finally, millions of taxpayer dollars from the Provider
Relief Fund have gone to facilities to fight COVID. AARP
strongly urges that the administration and Congress ensure that
these funds are directly used for the health, safety, and care
of residents and staff.
AARP's third point is to ensure safe access to in-person
visitation, following Federal and State guidelines, and to
require continued access to facilitated virtual visitation for
all residents.
Our fourth point is to ensure quality care for residents
through adequate staffing and oversight. We are deeply
concerned about staffing shortages at facilities--and even
before the pandemic. According to AARP's Nursing Home
Dashboard, over 25 percent of nursing homes across the Nation
have reported a staffing shortage since June of 2020.
Residents' health and safety are at continued risk without
adequate staffing.
Finally, oversight and enforcement are a shared
responsibility between Federal and State agencies. Oversight
from CMS and State survey agencies, including regular annual
surveys, is vital now more than ever.
AARP 's final point is to reject immunity and hold long-
term care facilities accountable when they fail to provide
adequate care to residents.
You know, when I speak to folks, young and old, about how
they want to live their lives, an overwhelming majority tell me
they want to live at home for as long as possible with the
support of family and friends. Helping people to remain in
their homes and communities would help alleviate some of the
challenges we are facing in our Nation's nursing homes. This
includes supporting family caregivers who make it possible.
Families across the country are looking to Congress and the
administration for swift action to protect the health and
safety of their loved ones living in long-term care facilities
now, and well into the future. We cannot wait any longer.
Thank you.
[The prepared statement of Ms. Bottcher appears in the
appendix.]
The Chairman. Thank you.
Let's go next to Ms. Moten, the Ombudsman. Ms. Moten,
welcome.
STATEMENT OF QUITEKA MOTEN, MPH, CDP, STATE LONG-TERM CARE
OMBUDSMAN, COMMISSION ON AGING AND DISABILITY, STATE OF
TENNESSEE, NASHVILLE, TN
Ms. Moten. Thank you. Good morning.
Thank you, Chairman Wyden, Ranking Member Crapo, and
distinguished members of the committee. I am Teka Moten, State
Long-Term Care Ombudsman for Tennessee.
I am honored to discuss my experiences, challenges, and
lessons learned while serving residents during COVID. I want to
first thank you for CARES funding and American Recovery Act
funding. It has greatly assisted in the provision of programs
and activities, as well as the procurement of equipment and PPE
in this time.
I sit before you as a Certified Dementia Practitioner,
trainer, and coach, as well as a former volunteer Ombudsman. I
have spent the entirety of my career in public service--
specifically, Asian programs and policies.
I began as State Ombudsman of Tennessee January 17, 2020. I
had less than 60 days to learn my role, staff, and major
stakeholders prior to the lockdown. Coincidentally enough,
there was also a tornado that affected the Nashville area and
the upper Cumberland region, and this affected a number of
long-term care homes.
Swedish for the term ``representative of the people,'' the
Ombudsman Program is an essential component to the oversight of
long-term care facilities. We operate as a community-based at-
the-
bedside advocacy program for the rights of residents.
We handle complaint investigations as laid out by the CMP
State Operations Manual. The major components of the Ombudsman
Program, fortified by the Older Americans Act, include a
mandated quarterly visit to our nursing homes by staff
Ombudsmen, and regular visits to communities by trained and
designated volunteer Ombudsmen who, at the average age of 70,
are very much a vital and integral part of our program.
COVID, alongside ensuing policies, disrupted the Ombudsman
Program's immediate access to residents. The inability to have
face-to-face meetings made it difficult to verify complaints,
assure confidentiality, and to readily gain consent for the
medical surrogates or POAs.
In addition, it made it difficult for us to advocate on
behalf of residents being discharged against their wishes,
oftentimes leaving them in behavioral health or medical centers
with the risk of losing their Medicaid. Particularly affected
by these major barriers are people living with dementia, those
who are aphasic or unable to speak, those who are deaf or hard
of hearing but have assisted technology needs, those without
the manual dexterity to pick up the phone, and those with that
ability who were without a phone or had to purchase their own.
Residents in fact were not silent. Lack of staffing and
inability to be with their families silenced them. But staffing
issues were nothing new in the most-regulated industry in this
country.
Nursing homes were already dealing with a workforce
shortage, and COVID exacerbated that issue further. Staff
members got sick, as you have already heard. Many had to
quarantine, and some faced a lack of child care options.
What resulted was an overall decline in the quality of care
that our residents received. Throughout the country, Ombudsmen
received complaints of dehydration, unanswered call lights, a
lack of basic care and assistance--cleaning, bathing, feeding--
but most identifiable probably, a lack of repositioning, which
left residents in the bed, resulting in an exponential increase
in bed sores.
Unchanged catheters and pressure sores resulted in sepsis,
and sometimes death, for our residents. There are issues of
dignity and hygiene stemming from residents having to sit in
their own feces and urine for hours on end, delayed discharges
to hospistals for serious conditions, access and transport
issues to dialysis and other appointments, and an uptake in
facility-initiated hospice.
Residents dealing with COVID, its reoccurrence, testing,
and room changes had to deal with resident isolation. This led
to emotional distress and physical decline.
I can remember, vividly, calls from skilled rehab residents
who would recount their experience in facilities. For me, the
toughest part was knowing that if we received calls to our
hotline on the weekend and the evenings, it was more than
likely it was a resident who knew that there were going to be
less staff in the building.
Worried family members also shared their concerns for
unkempt residents as they looked on in discontentment at
disheveled hair, unbrushed teeth, and filthy fingernails. This
added to our task of helping family caregivers adapt to a
different type of caregiver's role, especially for those moving
into a facility in the midst of COVID.
But for those who would take their final breaths in nursing
homes, the term ``compassionate care'' altogether presented
another set of challenges for us in dealing with the discretion
of facilities.
Ombudsmen have worked tirelessly throughout the last year.
Ideally, the worst has subsided, yet the fact remains that
residents of long-term care make up less than 1 percent of the
U.S. population, but as of March 4, 2021, they account for 34
percent of all deaths in America.
As we move forward, it is my hope that we can lean on a few
actionable items: for facilities, a comprehensive plan for
recruiting and retaining staff; for the Ombudsman Program,
consideration as an essential part of a system that responds to
and supports the safety and welfare of residents, regardless of
any status the State may bestow upon them; and last but not
least, for the residents remaining in our facilities, the
loving embrace of family, friends, pets, and a return to some
version of normalcy.
[The prepared statement of Ms. Moten appears in the
appendix.]
The Chairman. Thank you, very much.
Our final two witnesses will be John Dicken, Director of
Health Care at the Government Accountability Office, where he
has worked since 1991. He oversees a portfolio of audits on
health-care questions, and he has been before us before, and we
appreciate it.
And then we will close with Dr. David Gifford, an M.D. and
a master of public health, chief medical officer of the
American Health Care Association and a geriatrician.
But first, let us proceed now to Dr. Konetzka.
STATEMENT OF R. TAMARA KONETZKA, Ph.D., LOUIS BLOCK PROFESSOR,
DEPARTMENT OF PUBLIC HEALTH SCIENCES, BIOLOGICAL SCIENCES
DIVISION, UNIVERSITY OF CHICAGO, CHICAGO, IL
Dr. Konetzka. Chairman Wyden, Ranking Member Crapo, and
distinguished members of the committee, thank you for holding
this hearing.
My name is Tamara Konetzka. I am a professor of health
economics at the University of Chicago, and I have been
conducting research on long-term and post-acute care for more
than 25 years. I have intensely studied COVID-19 in nursing
homes during this pandemic. I will focus my remarks on what we
have learned from research, followed by recommendations.
First, what do we know about the predictors of nursing home
cases and deaths? A large body of evidence shows that the two
strongest and most consistent predictors of worst COVID-19
outcomes are larger nursing home size and COVID-19 prevalence
in the surrounding community.
Given two similar nursing homes with an outbreak, being in
a virus hotspot is associated with five more deaths. Equally
important are nursing home attributes that are not linked with
COVID-19 outcomes.
Multiple rigorous studies have found no meaningful
association between COVID-19 outcomes and standard quality
metrics. Even prior infection control citations were not
associated with COVID-19 outcomes. These results suggest that
high quality and good infection control are not enough in this
pandemic.
The numbers bear this out. At this point, more than 99
percent of nursing homes in the Nation have had at least one
COVID-19 case. And more than 80 percent have had at least one
death. This is clearly not a bad apples problem, and no subset
of nursing homes has found a magic bullet to keep the virus
out.
The single most important thing we could have done as a
Nation to reduce the tragedy in nursing homes over the past
year was to use public health measures to control the spread of
the virus in the general population.
Second, what about disparities? As Chairman Wyden
mentioned, our research found striking disparities by race.
Nursing homes serving more residents of color experienced more
than three times as many COVID-19 cases and deaths as those
serving primarily white residents.
Why? Most of the disparity can be explained by what race is
correlated with. Residents of color are more likely to live in
larger facilities in neighborhoods where COVID-19 is prevalent.
Third, are there any predictors of bad outcomes that are
more amenable to change? In the often-contentious world of
nursing home policy, it is difficult to find things that
everyone agrees on, but here is one. On average, nursing homes
lack sufficient numbers of staff to provide the quality of care
we would all like to receive.
In our research, we found that having more staff did not
reduce the probability of a COVID-19 outbreak, but nursing
homes with the most staff hours experienced fewer deaths and
cases once an outbreak occurred.
The effects of staffing are still dwarfed by the effect of
community spread. But increasing staffing represents a clear
intervention that could improve care and save lives during this
pandemic and beyond.
This evidence base suggests several policy recommendations
moving forward.
First, policies implemented during the past year that
reward or fine facilities based on COVID deaths are not
appropriate in a crisis. Instead, I strongly support the
allocation of American Rescue Plan funds to provide strike
teams to rapidly fill staffing gaps during an outbreak.
Second, we must provide greater assistance to large
facilities in communities of color. Such facilities do not
typically earn performance bonuses, but may be most in need of
resources.
Third, the American Rescue Plan put substantial funding
into improving infection control. Although improvement is
certainly necessary, we should recognize that this is a
solution to a relatively narrow set of problems, a solution
that would not have avoided the tragedy of the past year.
Fourth, CMS should immediately release facility-specific
data on vaccination dates and rates and demographics, including
race and ethnicities, essential for both research and policy.
Consumers who are considering nursing home care also have a
right to know what percent of residents and staff have been
vaccinated.
Finally, direct-care staffing in nursing homes needs to be
increased. Addressing this challenge requires resources, which
is where the agreement about staffing ends and the harder
problems begin.
Many argue--and I largely agree--that America's long-term
care system is grossly under-funded. At the same time, the
growing role of related-party transactions and private-equity
ownership makes it difficult to see where taxpayer money is
being spent, and what profit margins truly are. Greater
transparency about the flow of money is urgently needed.
We will never achieve adequate nursing home quality unless
we find a way to support the workforce. In addition to low pay
and few benefits, the job of direct-care nursing staff is
difficult, often dangerous, and emotionally and physically
taxing. Add the risk of a potentially fatal infectious disease,
and it is amazing they show up. Addressing this challenge is
the best way to honor the memory of the more than 1,900 nursing
home workers and all the residents who have died from COVID
thus far. We cannot turn back the clock to prevent the tragedy
of the past year. We can at least take steps to learn from it.
Thank you.
[The prepared statement of Dr. Konetzka appears in the
appendix.]
The Chairman. Thank you very much.
Our next speaker will be John Dicken.
STATEMENT OF JOHN E. DICKEN, DIRECTOR, HEALTH CARE, GOVERNMENT
ACCOUNTABILITY OFFICE, WASHINGTON, DC
Mr. Dicken. Well, good morning, Chairman Wyden, Ranking
Member Crapo, and members of the committee. Thank you for the
opportunity to discuss with you findings and recommendations on
the Federal response to COVID-19 in nursing homes.
As characterized in the title of today's hearing, and as we
have heard this morning, the last year has indeed been a
national tragedy for nursing home residents and their loved
ones. Just over a year ago, a Washington State nursing home was
battling one of the first major outbreaks of COVID in the
United States.
Today, the pandemic has reached nearly all nursing homes in
the country. More than 130,000 nursing home residents have died
from COVID-19, representing nearly 30 percent of all COVID-19
deaths recorded by the CDC as of early February.
Even for those nursing home residents not infected, nearly
all have faced increased isolation and restrictions from loved
ones. The pandemic has also posed tremendous challenges to the
homes and their staffs. Notably, more than half a million
nursing home staff themselves have contracted COVID-19.
In response to this unprecedented national emergency, HHS
has taken a series of actions. These include providing guidance
to States and nursing homes, developing targeted inspections to
focus on infection control practices, and distributing testing
devices and vaccines to homes.
GAO continues to evaluate the Federal response to the
pandemic in nursing homes as part of a series of comprehensive
reports to Congress on the government-wide response. My
statement states a few key findings and recommendations from
these reviews during the pandemic, as well as our longer-term
work examining nursing home oversight prior to the pandemic.
With the ongoing administration of vaccines to nursing home
residents and staff, nursing homes may be beginning to see a
reprieve, as cases and deaths declined by more than 80 percent
as of February from their peaks in December.
Just last week, CMS updated its guidance to expand resident
visitations. This issue has posed an ongoing challenge in
providing residents the ability to have visitors--which can
benefit their overall mental and physical health--and
minimizing further COVID-19 outbreaks.
Other challenges nursing homes have faced in battling
COVID-19 include obtaining personal protective equipment and
conducting COVID-19 tests. Although these challenges are still
notable, they have generally shown signs of improvement.
Some new challenges have also emerged, such as reluctance
among some staff to receive a COVID-19 vaccine, and the need
for continuous vigilance with the emergence of more highly
transmittable virus variants.
GAO has made two recommendations specific to HHS's response
to nursing homes to date. The first recommendation is for HHS
to develop a strategy for having more complete data on COVID
cases and deaths in nursing homes, which were only voluntarily
reported until last May.
The second recommendation is to more systematically develop
a plan detailing if and how the Centers for Medicare and
Medicaid Services will respond to remaining recommendations
from a commission appointed by former Administrator Verma and
publicly reported last September.
To date, CMS has not yet implemented these recommendations.
We maintain the importance of these recommendations to better
inform the government's continued response.
We also made a number of recommendations to improve nursing
home oversight, as work completed prior to the pandemic, that
have yet to be implemented. For example, less than 2 years ago
I testified before this committee regarding GAO's report on the
abuse occurring in nursing homes. That report made six
recommendations to CMS, including that CMS require State
surveyor agencies to immediately notify law enforcement of any
reasonable suspicion of a crime against a resident.
These recommendations are particularly relevant during the
COVID-19 pandemic because, with reduced visitors, Ombudsmen,
and State surveyor presence, there may be a higher risk of
abuse going unreported.
In closing, GAO's recommendations could help address some
of the challenges nursing homes continue to face, and fill
important gaps in the Federal Government's understanding of,
and transparency around, data on COVID-19 in nursing homes.
Going forward, the spotlight that COVID-19 has placed on
the vulnerability of nursing home residents may be best used to
inform future pandemic responses and refocus on longstanding
challenges that place nursing home residents' health and safety
at risk.
This completes my prepared statement.
[The prepared statement of Mr. Dicken appears in the
appendix.]
The Chairman. Thank you very much, Mr. Dicken.
Dr. Gifford?
STATEMENT OF DAVID GIFFORD, M.D., MPH, CHIEF MEDICAL OFFICER,
AMERICAN HEALTH CARE ASSOCIATION/
NATIONAL CENTER FOR ASSISTED LIVING, WASHINGTON, DC
Dr. Gifford. Chairman Wyden, Ranking Member Crapo, and
distinguished members of the Senate, thank you for making long-
term care providers a priority as you examine how COVID-19 has
impacted the Nation, and for providing our association the
opportunity to share our members' challenges during the
pandemic.
AHCA represents over 14,000 nursing homes and assisted
living communities across the country, including not-for-
profit, for-profit, and government facilities. As a
geriatrician, I can attest that COVID-19 is the greatest
tragedy ever to impact our residents and their families.
Over 635,000 residents have been infected, and more than
130,000 have died, worse than any other infection or disease we
have faced. This virus has also affected health-care workers,
with over half a million becoming infected, and thousands
dying.
As you know, our residents are at the highest risk for
COVID-19 complications. More than half are over the age of 85
and suffer from multiple chronic diseases. Residents depend on
our nurses, our aides, support staff--including housekeepers--
to help them with their daily activities that require close
one-on-one contact like eating, getting dressed, and bathing.
COVID-19 has impacted every aspect of long-term care. For
nearly a year, family members were unable to visit. Residents
could not leave their room. They could not see the smiles of
the nurses and aides caring for them, hidden behind their
masks.
Our dedicated staff did everything they could to keep
residents safe, engaged, and happy. Meanwhile, they constantly
worried about becoming ill or infecting their family, as Ms.
Ramos clearly described.
Our hearts go out to the residents, their families, and the
health-care workers who have suffered through the past year,
separated from each other, in some cases forever.
Why did such devastation happen in long-term care? The
timeline in my written testimony demonstrates how our knowledge
of this virus continually evolved, but the public health advice
could not keep up, and as a result, it was typically too late.
For example, initial guidance was focused on a symptom-
based approach that we know is ineffective, since half the
people spreading the virus do not have symptoms. But guidance
for mask-
wearing for all staff did not come until June, 4 months into
the pandemic.
Compounding these challenges was the failure to make
nursing homes a priority. Despite numerous calls for help, it
took months to receive much-needed PPE. In many circumstances,
staff had to use their ingenuity to make their own masks,
gowns, and face shields.
I recall getting a call one weekend asking if rain ponchos
worked better as gowns than trash bags. As we now know, COVID-
19 outbreaks in nursing homes are principally driven by how
many people in the surrounding community have COVID, as Dr.
Konetzka testified.
But testing kits needed to detect asymptomatic carriers of
the virus were not provided to nursing homes until almost 6
months into the pandemic. As a result, staff in these
communities, often unwittingly, brought COVID-19 in the
building.
With these delays, even the best nursing homes with the
most rigorous infection control practices could not stop this
highly contagious virus. The long-term care community was left
behind, forgotten, and even blamed. This further demoralized
the staff, who were risking their lives and trying their best--
with inadequate support.
It is critical that we determine what we can do to keep
this from ever happening again. We must reflect on the
challenges within the long-term care profession that this
pandemic has exposed and exacerbated.
We recognize that providers can and must do better to meet
the needs of the elderly. Prior to COVID-19--and only made
worse by the pandemic--the long-term care facilities struggled
to attract and retain a highly dedicated workforce,
particularly registered nurses, who are most in need during an
infectious disease outbreak. Our ability to find nurses and
other caregivers is correlated with the lack of availability
and proper funding.
As many academic experts have highlighted, chronic Medicaid
under-funding makes it a challenge for providers to compete
with hospitals for nurses and make infrastructure changes.
What we have learned from this tragedy is that it will take
considerable investment to make meaningful changes. We stand
ready to work with policy-makers and others to take bold
action. Earlier this week, AHCA and LeadingAge together
announced the Care for Our Seniors Act, a set of proposals
focused on clinical improvements, strengthening and supporting
our workforce, improving oversight--particularly for
chronically poor-performing facilities--and modernizing our
physical structures.
The good news is that nursing home residents and staff were
made a priority to receive the remarkably safe and effective
COVID-19 vaccine. As a result, cases and deaths have declined
dramatically since mid-December. Making them a priority for the
vaccine demonstrates the power of putting long-term care and
our Nation's seniors first during emergencies.
On behalf of the staff and the residents in nursing homes
around the country, I would like to thank the Senate and the
members of this committee for your dedication and leadership
during this pandemic.
We look forward to working with you on implementing
constructive solutions to combat COVID-19 and usher in a strong
long-term care system.
[The prepared statement of Dr. Gifford appears in the
appendix.]
The Chairman. Thank you, Dr. Gifford. And all of you have
been excellent.
I am going to begin my questioning with you, Ms. Ramos,
because I was listening to what you said, and it was clear you
too are at the center of this collision of mismanagement. You
talked about the under-staffing issue. You talked about the
problems getting PPE, protective equipment. You mentioned the
fact that you all were in the dark with respect to getting
information.
And I think, apropos of information, I heard you say that
there was concern among health-care workers--and you,
initially--about getting vaccinated. Do you think getting more
good information out, particularly in communities of color,
about the success of vaccinations, would really be helpful?
Ms. Ramos. Yes. I had to do my own research. I was scared
to get vaccinated. I talked to my union rep about the vaccine,
and I got the information. But I think most of my co-workers,
they felt the same way I did. They did not want to be guinea
pigs of the system, because what we went through was horrible.
We did not get the help that we needed, and we felt like the
companies just wanted us to be the guinea pigs.
But if there is more information in the community--because
we all have different backgrounds, we all speak different
languages, and we come from everywhere--so if there are more
resources in the community that they trust, it would be easier
for them to get vaccinated.
So they should talk to the church members, or somebody who
speaks their language, to the leaders of the communities, to
help them out.
The Chairman. You know, your point is so logical, it is
almost like you are being too logical for Washington, DC,
because you should not have to be a private eye to get this
information. So we are going to follow up with you on that. And
again, I just so appreciate your leadership.
Dr. Konetzka, let me turn to you. I am very appreciative of
the fact you mentioned the strike teams, because I think they
are extraordinarily important in bringing the expertise to this
issue. We had a floor fight during our 24-hour day where we had
to defend it, and fortunately we prevailed.
I would like you to amplify on your concern, because I
share it, about private equity getting more involved in the
field. Because my concern is--and I heard Ms. Ramos make
another point, that she is concerned that all they are
interested in is money and the like. This trend towards more
private equity looks to me like something that the Finance
Committee should be digging into. And I thought maybe you could
amplify on your statement.
Dr. Konetzka. I agree. I think it would be a good thing if
the Finance Committee could look into this. The increasing role
of private equity in nursing homes, along with other complex
arrangements like the related-party transactions, is a problem.
There is really interesting recent research showing that
nursing homes bought by private equity subsequently have higher
revenues, but lower staffing and worse patient outcomes. And
when those revenues are coming from public funds, this is not
acceptable. And I think regulators have been reluctant to
interfere with ownership transactions in the industry, an
industry that is mostly for-profit, but it may be time to do
so--at least in the sense of transparency.
So we should think about assistance, or potentially
increasing reimbursement rates so that we at least know where
the money is going, even the current reimbursement rates.
The Chairman. We are going to be calling on you again on
this issue, because it seems to me this is an area that has not
gotten the oversight and the accountability that is needed. And
I am glad that you have lit this concern up in front of the
Senate Finance Committee.
A question for you, Ms. Moten, and I so appreciate your
Ombudsman role. When I was director of the Gray Panthers, we
worked with the Ombudsmen. And dollar for dollar, you all make
such a big difference.
We have been reading about how these rating systems are not
doing a particularly good job of rating. What would you do with
these and have, as counsel for the Finance Committee, some
direction at improving them?
Ms. Moten. You know, honestly I am not exactly certain what
I would do to change the rating system. I think that a lot of
what we see as Ombudsmen is that facilities are on their best
behavior when help is in the building oftentimes.
And so I think that some more impromptu approaches to that
will probably be the best way to work through those issues.
The Chairman. Well, three cheers for getting us started on
that because, when I was on the nursing home board, if they
knew you were coming, everything was perfect. And that is a
very important suggestion. We will call on you again.
All right, I am over my time. And our next member, we see
our friend, Senator Crapo.
Senator Crapo. Thank you very much, Mr. Chairman.
And I will start with you, Mr. Dicken. In your testimony,
you mentioned a statistic, if I got it right, that the deaths
in nursing homes had gone down by 80 percent by February. Could
you give me that correct statistic again? And if that is
generally correct, could you tell me, do you have an idea as to
what we can attribute that reduction to?
Mr. Dicken. Yes. Thank you, Ranking Member Crapo. And you
do have it correct. What we have seen from reporting from HHS
is that, from the peak of cases and deaths in nursing homes in
December until reporting early last month, the cases and rates
have declined by 80 percent. And we are pleased that that
decline has continued even beyond early February.
Certainly, you know, we are continuing to evaluate kind of
what those factors are. There is still a need for continued
vigilance. That is a sharper rate of decline than we have seen
throughout the broader community. There have been declines in
cases and rates outside of nursing homes, and while it does
seem to be sharper, certainly the prioritization of
vaccinations of nursing home residents and staff is a key thing
to look at in why it is an even faster decline in the rates
recently for nursing homes.
Senator Crapo. Well, thank you. It seems to me that
something must be being very helpful. Something is working. And
we need to identify exactly what that is. And so I would
appreciate your assistance in that.
GAO has issued at least four reports regarding the Federal
and State response to COVID-19 in nursing homes. And I do not
want to use up all my time on this, because I have a few other
questions for others, but you mentioned that Seema Verma had
issued some recommendations that have not yet been implemented.
And I believe that GAO has made a number of recommendations in
its report.
Could you pick just a couple, like one or two of the most
important recommendations you think are yet to be implemented
and need to be?
Mr. Dicken. Yes, and I will be brief. As you noted, the
former CMS Administrator had a commission that made over 27
recommendations on ways, both short-term and long-term, that
CMS could help respond to the pandemic.
CMS took a number of steps, but we have recommended that
they do a more systematic plan on how they can more fully
continue to draw from the expertise of the commission that was
appointed, and we would recommend that that would help improve
the Federal response.
The other one I would highlight is that the data is very
important for oversight, and for transparency, and that prior
to May, that was voluntary. And we recommend that CMS identify
a strategy to have more complete data for the early months of
the pandemic. That is very important not only for ongoing
response, but for understanding lessons from the pandemic over
the course of time.
Senator Crapo. Well, thank you. We want to work with you,
and with all of our witnesses. I know our Ombudsman--and I will
not be able to get to you in my questioning--but there are a
lot of recommendations out there from all of you.
We need to know what is working and what needs to be done
better, and I encourage you to give us that information.
I would like to move quickly to Dr. Gifford. Doctor, how
did the AHCA respond to certain State directives mandating that
long-term care facilities admit active COVID-19 cases?
Dr. Gifford. Well, thank you, Senator Crapo, for that. I
think, as we heard from Ms. Ramos and others, there was just
chaos in May and April. The nursing homes were terrified of
this COVID. Families were terrified. Staff were terrified. And
hospitals were terrified.
We saw in some cities, you know, lines forming in
hospitals, and creating intensive care units in the parking lot
in tents. And so there was sort of a lot of trying to figure
out what was going on out there. And as a result, we saw
variations and different recommendations that were out there.
Nursing homes typically play an important role in
emergencies in that they take on patients out of the hospital
to free up hospital beds to deal with the emergencies. In this
situation, though, freeing up the beds and taking people out of
the hospital could potentially lead to further spread, and so
that was sort of a worrying concern that we had. But we
realized we needed to play a role in the health-care decision,
because any decision that was going to be made was going to
have dire consequences.
If you decide not to move people out of the hospitals, you
move people into parking lots. If you move people into nursing
homes, you might create spread. And our position was to try to
create special units and make sure there was enough PPE and
enough staff that were out there that was really lacking. And I
think you have heard that from the testimony that was out here
so far.
Senator Crapo. Well, thank you. I see my time has run out.
It runs out quickly. For those of you whom I did not get to, I
will submit some written questions to you. And I would really
welcome your responses to these. Thank you very much.
Thanks, Mr. Chairman.
The Chairman. Thank you, Senator Crapo.
Senator Stabenow?
Senator Stabenow. Well, thank you very much, Mr. Chairman,
for doing this very, very important hearing. And I think we all
know this last year has been a horrible situation. And we have
to say this started with a lack of seriousness by the former
President and the lack of action by the administration. And
certainly that has been something that we have seen where, in
nursing homes, it has played itself out in a very, very serious
way.
High-quality staff are what make high-quality nursing
homes. And a recent report, as has been said, found that the
average yearly turnover rate for nursing home staff was 128
percent. So 128 percent means the average staff completely
turned over in a year. And some nursing homes had staff that
changed over every few months, which is a very, very serious
issue, obviously.
Ms. Ramos, first of all I want to thank you for your
incredible work, particularly over the past year. I am really
in awe of your courage and your resolve, as well as the
colleagues that you work with.
You said at one point you were caring for 26 critically ill
patients. Can you talk a little bit more about the impact of
staff turnover on patient care?
Ms. Ramos. Thank you for your question. So on the Mother's
Day of last year, we had critically ill patients with COVID.
They were all in bed. So there was me and another aide for 26
residents, and a nurse and a housekeeper.
We had to, you know, check their temperature, check their
oxygen every 15 minutes. I was in an Alzheimer's unit, so it
was very challenging, because our residents kept taking off
their masks. So we kept going to their rooms because the oxygen
was dropping, because they could not keep their masks on.
So the quality of care, it was horrible. We were only two
CNAs. And most of our residents were in bed. We could not sit
there with them and talk to them while they were dying. We
could not keep them hydrated when we knew that that was a part
of it, that you had to keep them hydrated because they could
not hold a glass of water.
So we had to pick and choose, which is a thing that we have
to do all the time--this did not start with COVID. So sometimes
we have to pick and choose who are the critical residents for
us to assist first. And that is a thing we do every day. And I
do not think we should be put in that position where we
constantly have to pick and choose what resident to care for,
because we love them. We care for them. And the quality of care
that they deserve is not there right now.
Senator Stabenow. Well, and from your perspective--this
sounds horrible, trying to figure this out when you can, and I
am sure you are doing everything you can to care for people.
From your perspective and your experience, what are the main
reasons that nurses and CNAs leave their jobs at nursing homes?
Ms. Ramos. Well, we do not want to leave our jobs. I had a
thought, you know, during this pandemic. I was like, ``I cannot
do this anymore.'' But then I said to myself, ``You know, right
now is when they need me the most.'' So why would I leave them
when the family members cannot come in? So I got up, sticking
it out, and went back to work, because they need me.
The reason why a lot of CNAs and nurses leave nursing homes
is because the workload is a lot. We are constantly working
short-staffed, and we, the CNAs, we make low wages. And we have
to work in multiple nursing homes to pay our bills.
So we do not want to leave nursing homes, but we have to do
what we have to do for our families.
Senator Stabenow. Of course. And I hear over and over again
from our nursing homes that are really doing quality work as
well, that not having enough nurses, right, and CNAs, is also,
along with pay structure, really an issue.
One of the things right now is, staff turnover information
is not made public, and it seems to me that that would be
important for patients and families.
So if I might ask, Dr. Konetzka--you are on the Technical
Expert Panel that advises CMS. Do you agree this information
should be made public?
Dr. Konetzka. Yes. I think turnover information is really
important. There is a large body of literature tying higher
turnover to worse patient outcomes in nursing homes. So I think
that information could be useful.
I think there are bigger gaps in terms of what we report,
such as quality of life and customer satisfaction. But knowing
turnover could be helpful to consumers.
Senator Stabenow. Thank you. And then just finally--I know
I am running out of time--but, Dr. Konetzka, in your opening
statement you included recent findings that nursing homes with
higher proportions of non-white residents experienced death
counts three times higher than those facilities with higher
proportions of white residents.
So, like in many other areas, we have seen longstanding
racial disparities put under bright lights, under COVID,
certainly. But could you, based on your research--what would
your recommendations be to address this?
Dr. Konetzka. I would divide that into short-term and long-
term recommendations. I think in the short term, we need to
make sure the assistance gets to those facilities and
communities of color, because they are the ones experiencing
the worst outcomes. So strike teams, for example--we have to
make sure they get to those facilities.
I would say also with vaccinations, we do not have the data
to know this. The data need to be released. But we need to make
sure that vaccination is equitable, and that people in nursing
homes in communities of color, and people out in the community
in those same neighborhoods, get vaccinated.
The Chairman. This is an incredibly important topic, and we
are going to return to it. We just have to move on because we
have so many other Senators waiting.
Senator Stabenow. Thank you.
The Chairman. Our next Senator is Senator Grassley.
[No response.]
The Chairman. No Senator Grassley.
Senator Cantwell is next.
Senator Cantwell. Thank you, Mr. Chairman. Thank you for
holding this important hearing.
The State of Washington was one of the first States to
record the impact of the COVID-19 virus. And many people may
remember, on February 10th the Life Care Center in Kirkland, WA
reported an outbreak of COVID-19 within the facility that
ultimately would claim 46 lives.
In the State of Washington, nearly half of the reported
deaths have been in long-term care facilities. That is why in
the American Rescue Plan there is included $750 million of
support for nursing homes and skilled nursing facilities,
including $500 million for strike teams and $200 million for
infection control. This was something my colleague, Senator
Casey, in his leadership made part of the COVID-19 Nursing Home
Protection Act, which I also co-
sponsored with him, which was very important legislation.
This, I believe, is critical, so I would like to ask Dr.
Konetzka how this utilization of both strike teams and staffing
issues can help protect nursing home residents during these
times of major outbreaks?
Dr. Konetzka. Thank you for that question. I think the
strike teams are essential. I think they have been a good tool
all along for States that have decided to do that. The problem
is that nursing homes, even prior to the pandemic, were often
under-staffed. And the pandemic exacerbated that, for all the
reasons we have been talking about.
Staff were sometimes getting sick, or afraid to bring the
virus home to their families, or needed to stay home with kids
who were learning online. And so you really could not implement
the best practices that we now know can address a COVID
outbreak, such as testing all residents as soon as there is a
case in the facility, such as separating residents and
assigning dedicated staff to COVID-positive versus COVID-
negative residents so they do not have to go back and forth
between the two.
All of those things take staff. And in the short run, we
cannot incentivize facilities into finding more staff and
hiring them in the middle of a crisis, in the middle of an
outbreak. And so the strike teams are really essential to fill
those gaps. Time is essential. Once you have an outbreak, you
really need to deal with it immediately. And that is what the
strike teams enable.
Senator Cantwell. Well, my question is, what else can you
do in the coordination? I think in this case the pandemic was
new to the United States. We were at the very first impact;
Life Care Center of Kirkland was at the very first initial
impact. In fact, I think the University of Washington stepped
in and tried to help, both in identifying and testing, but it
was almost that, at that point, we needed more leadership
beyond just the facility itself.
So what else should we be doing to consider the
coordination with the strike teams of almost, if not global
technically, but theoretically global input to help on these
crises?
Dr. Konetzka. Yes, to me this is about policy leadership as
well. I think the strike teams have mostly been facilitated
through States. And the strike teams need to come, of course,
with some coordination and technical assistance.
There needs to be State leadership to identify which
nursing homes really need this help, and coordination in
getting them there and filling the necessary gaps.
Senator Cantwell. Do you think we have these protocols in
place now?
Dr. Konetzka. I think it is unclear. I think there are
still some things that need to be worked on in terms of overall
coordination.
Senator Cantwell. I think you are right too. That is why I
asked the question. I think we really need to think about this
in the sense of protocols that need to be established, because
this is such a painful experience for everyone. And I think
knowing how we could improve upon it in, not just the strike
teams but the larger coordinated effort in marrying everything
together, I think that would be great.
Thank you so much. Thank you, Mr. Chairman.
The Chairman. Thank you, Senator Cantwell.
And our next questioner will be Senator Thune.
[No response.]
The Chairman. Senator Thune, are you out there?
[No response.]
The Chairman. Senator Menendez?
[No response.]
The Chairman. Senator Portman?
[No response.]
The Chairman. Senator Cardin?
[No response.]
The Chairman. Senator Toomey?
[No response.]
The Chairman. Senator Brown?
[No response.]
The Chairman. And I see Senator Cassidy.
Senator Cassidy. Super. Am I up?
The Chairman. Yes.
Senator Cassidy. Good. Let me ask this, because when I
speak to providers--I will probably go first with you, Dr.
Gifford. I spoke to folks back home who ran nursing homes. They
had an incredible problem with staffing during the pandemic.
And what they told me is that the initial stimulus checks that
were as generous as they were--as we know, about 80 percent of
folks were making more money on stimulus checks than they were
working--killed their ability to recruit staffing.
Now this does not address the longer-term staffing issues,
but it does beg the question of whether or not the decrease in
staffing associated with the pandemic could have been
associated with government policies which in effect paid more
to folks not to work than to work.
Dr. Gifford, any thoughts on that? And then I will probably
come back to you, Dr. Konetzka.
Dr. Gifford. Thank you, Senator Cassidy. You know, we have
heard, I think from all of us, that the workforce is a
challenge, and it was exacerbated with COVID. A lot of health-
care workers were home sick and could not come in, so that even
made it worse.
We did put together a training to train many of the
unemployed who were out there, and we had over 200,000 people
come through training to be temporary aides, whom we would love
to see get into permanent aide positions and move on to become
nurses out there.
So there was a lot of demand for people coming in and
helping to work. I think a lot of it was more around the
licensure and the bureaucratic aspects of getting health-care
workers into this sector. That was the biggest challenge that
we faced, and we are really thankful for many of the States and
the Federal Government for some 1135 waivers to make that more
effective.
Senator Cassidy. And, Dr. Konetzka, it does seem intuitive
to me though, that if somebody can make 20 percent more on
transfer payments as opposed to working--and if you are doing
so, by the way, it suggests that you are kind of economically
challenged to begin with--that there was an incentive for folks
to retire from the workforce in order to do this.
You are the economist. What are your thoughts?
Dr. Konetzka. Nobody has collected data on that. I think
what I have found anecdotally from talking to people who work
in nursing homes is that that really was not a major reason why
nursing homes were under-staffed.
And I think when you look at people who work in nursing
homes, some of whom are on this panel, people generally have
different motivations for doing that work. And you really
cannot be in it for the economics solely, if you work in a
nursing home for low wages, take care of people, endure
sometimes really physically and emotionally taxing work.
So I would guess--although we do not have data on it--that
a lot of the workforce shortage had to do with pandemic-related
reality--getting sick, having family at home that you do not
want to bring the virus to, or having kids at home--plus
competition from other sectors. Hospitals were also competing
for these same workers----
Senator Cassidy. So let me ask you----
Dr. Konetzka [continuing]. So I don't think incentives were
a major force.
Senator Cassidy. Got it. Let me ask you this. Again, if I
speak to folks from the industry, they will say that many of
them--and we noticed the racial disparity among those
affected--that the racial disparity suggests--we do not know
for sure--that the nursing homes most impacted were those which
are most likely to have Medicaid as a primary payer.
Now to what extent do low reimbursement rates affect the
ability of someone to have that extra resiliency required to
handle something like a pandemic? I will stay with you, Doctor.
Dr. Konetzka. Okay. Are you asking about the resiliency of
the workers themselves?
Senator Cassidy. No, the nursing home. The ability to have
that kind of redundancy of systems, the extra supplies on hand,
the kind of--and really now, I am a doctor. So I walk into an
older nursing home, and the rooms are smaller. The halls are
more narrow. If you walk into something built for assisted
living in which there is a payer mix, in which there is not
just Medicaid but there is also private pay, you end up having
better facilities, frankly, newer, better kept-up.
So to what degree do low Medicaid reimbursement rates
impact the ability of a nursing home to be better prepared for
an incident such as we have seen?
Dr. Konetzka. I think it is a big problem. There is a lot
of controversy here. I think that the long-term care system in
this country is generally underfunded, and a lot of that is
because we depend on Medicaid. And the Medicaid rates in
nursing homes in many States are really quite low.
When we look at the high Medicaid facilities, they tend to
have the lowest staffing ratios. They tend to have very little
slack. They are always putting out yesterday's fires. And when
you are hit with something like a pandemic, they are the least
likely to be able to deal with it.
Senator Cassidy. We are over time, so I will ask you a
question for the record. If you did a regression analysis
controlling for your payer mix being predominantly Medicaid,
how much does that obviate the racial aspect of this, knowing
that there is somewhat of a correlation between race and being
on Medicaid as a primary payer? We are out of time.
And I just want to give a shout-out to Denise from
Louisiana. Denise, good to see you. It is always wonderful to
see a friend as a panelist.
I yield back.
The Chairman. I thank my colleague.
Next is Senator Portman.
Senator Portman. Thank you, Mr. Chairman, and thanks for
fitting me in. I want to talk a little bit about home and
community-based services, and get the reaction from this great
panel of witnesses.
In Ohio, about 40 percent of our COVID deaths were in
nursing homes. And that is not atypical, unfortunately, around
the country. We tend to have a little higher percentage of
people in nursing homes than in other States--but 40 percent.
This makes it really the focus, and really the worst part of
our crisis: 7,000 nursing home residents in Ohio lost their
lives over the past year.
It has improved recently, dramatically, because of the
vaccinations, and I am excited about that. But in the meantime,
it has been a huge problem.
Long-term care of course is really important to ensuring
seniors, and people with disabilities, can live meaningful
lives. And while nursing homes are essential to our country, as
is a long-term care system, they are not the only ones who
offer this care.
For years, I championed this push towards home and
community-based services, or HCBS, where we can offer long-term
care in residential settings that are more personalized and
allow beneficiaries to live in their own homes, near to their
family and their friends and their familiar surroundings.
This is what we know about HCBS care: it costs less than
nursing home care; it produces similar or better outcomes; and
people are happier in it. Furthermore, Ohio data has shown that
only .3 percent of all beneficiaries with severe disabilities
receiving HCBS died of COVID this past year, or about 120
deaths. So it was more successful in avoiding the fatalities
with regard to COVID.
Because it works, last year we passed two major efforts
that the chair and ranking member and others have supported. I
appreciate that. We passed the Ensuring Access to DSPs Act,
which allows people on Medicaid to use direct support
professionals for HCBS care, to have them assist with their
hospital care, to help improve outcomes, and to get them back
home quicker.
That was really important, particularly for the
disabilities community, and Medicaid helps cover that. We also
passed the EMPOWER Care Act, which authorizes the Money Follows
the Person program for 3 additional years. I would like to have
gone further on that, and again many colleagues on the other
side of the aisle have helped on this. But it helped transition
people from nursing homes to HCBS care.
My question to the panel is this: when the pandemic was
beginning, what could we have done to have better utilized HCBS
services to have potentially prevented some of these deaths?
And second, what policy changes should we now consider in order
to further promote such services?
And it is open to the panel.
Dr. Konetzka. I will start. I think it is a--I thank you
for your efforts to expand home and community-based care. I
dream of a system where the funding mechanisms are smooth
between nursing homes and home and community-based care, and
people and policy-makers can decide how to target that care
appropriately, and people can get care where they would like.
I only caution that it is not a panacea, that we probably
will always need nursing homes. And there are some cases in
which home and community-based care can lead to worse outcomes.
I think we have to be very careful about targeting, but I think
that expansion of home and community-based care in a pandemic,
or beyond, is critical.
Senator Portman. Thank you.
Mr. Dicken, have you looked into this for GAO?
Mr. Dicken. Yes; thank you. It is certainly a really
important question. I certainly agree that it is important,
especially in the sense to make sure that, at any time, people
are getting appropriate long-term care in the appropriate
setting.
In this area, there is much less Federal information and
data on what is occurring in home and community-based settings,
or assisted living and nursing homes. I know that today's
hearing is focused on some of the limitations on what is known
within nursing homes.
You were able to indicate some Ohio-specific information,
and there is information at the State level. But many of the
same vulnerabilities exist for the population that is at risk,
that needs direct support.
And we have heard similar types of challenges, of things
like having adequate protective equipment, staffing challenges.
So similar types of challenges may be less of a problem in a
congregate setting, in some other settings. But also there is
much less information at the Federal level on what is occurring
in settings outside of nursing homes.
Senator Portman. So more data is needed. And if we had that
data, we would have a better understanding of what the
different outcomes are.
Mr. Dicken. That would be helpful, yes.
Senator Portman. Ms. Ramos, or Dr. Gifford, any thoughts?
Dr. Gifford. Go ahead, Ms. Ramos.
Ms. Ramos. I think that, in the nursing homes, we need
oversight. And Congress is the only one that can have that law
passed. Right now, we are fighting on the State level, but it
is not just in our State that we have these issues in the
nursing homes. It is across the country.
And our union is fighting really hard for us to pass the
bill so that everyone in the State, and in this country, will
have a law that will support the staff and the patients'
quality of care.
Senator Portman. Thank you, Mr. Chairman.
Dr. Gifford, if you have additional thoughts, I would love
to hear them, maybe with a written response. Thank you, very
much. Thank you, Mr. Chairman.
The Chairman. Senator Cardin was here before Senator Brown.
I apologize to my colleagues for the juggling. Senator Cardin
is next, and then Senator Brown.
Senator Cardin. Well, thank you, Mr. Chairman. I appreciate
that very much, and I appreciate the panel. This is obviously
an extremely important subject. We know that nursing home
safety has been a critical part of dealing with COVID-19.
I appreciate the challenges that we have had with
personnel, with safety of the personnel as well. I want to talk
about an issue that was present before COVID-19, and that is
that nursing homes have----
[Pause.]
The Chairman. Senator Cardin, we seem to have some audio
issues on your end. Can you hear me?
[No response.]
The Chairman. Why don't we go to Senator Brown, and then we
will go to Senator Cardin.
Senator Brown. Thank you, Mr. Chairman.
Just last month researchers from leading institutions
across the country published a working paper on private equity
investment in health care, specifically nursing homes. They
studied Medicare data from 18,000 nursing home facilities over
a 12-year period, examining patient outcomes at private,
equity-owned facilities.
The results are disturbing. Let me quickly summarize.
Researchers found private equity firms tend to shift money away
from patient care, cutting the number of hours that front-line
nurses spend providing care to patients. They also--and Ms.
Ramos, I am sure, is familiar with this, because of the union
that she is a part of that represents some of these workers--
they also found that patients at private equity-owned
facilities were more likely to be given anti-psychotic drugs.
They found that patients who receive care at private equity-
owned facilities are more likely to die. In fact, the
researchers found that more than 20,000--20,000--Medicare
beneficiaries died as a result of private equity-ownership of
nursing homes during that sample period of 12 years. Finally,
they found that taxpayer spending per patient episode increased
by 11 percent.
To summarize, the study found that when private equity
firms acquire nursing homes, they cut staff, they prescribe
more dangerous drugs, more patients die, and taxpayers pay more
money.
In November 2019, Senator Warren and I sent letters to four
private equity firms that invest in nursing home care and other
long-term care services to request information on how these
private equity firms manage their facilities.
So, Mr. Chairman, I would like to ask unanimous consent to
enter this paper by Atul Gupta and his colleagues, as well as
the letters that Senator Warren and I sent out to these private
equity firms and their responses, into today's record.
The Chairman. Without objection.
[The documents appear in the appendix beginning on p. 61.]
The Chairman. And I would note, Senator Brown, I have been
asking some of those same questions, so I very much appreciate
it. Go ahead.
Senator Brown. Thank you. We also see this private equity
issue--I'm the new chair of the Banking, Housing, and Urban
Affairs Committee. We see private equity firms, starting in
Iowa, we believe, but all over the country, private equity
firms buying up manufactured housing, so-called trailer parks,
and squeezing those generally low-income residents.
So we see it throughout our economy. My question--and I
have a follow-up question too--Ms. Ramos, two questions for
you.
First--and make your answer as short as you can--talk about
the difference between what adequate staffing and an under-
staffed shift means for your patients, and what it means to you
and your colleagues, if you would, Ms. Ramos.
Ms. Ramos. Thank you for your question. So with more
staffing, we can give the residents better care. For example,
if a resident asks me--if two residents ask me to go to the
bathroom, I have to pick and choose which one of them to take
to the bathroom first.
So when we have more staff, another aide can help the other
one. But when we are short-staffed, if I am in the bathroom
with one of the residents and a patient has fallen, like a
patient fell in the dining room, the nurse is calling for help,
we have to leave the resident who is in the bathroom and go to
help the other resident who just had a fall.
So those are the types of things that we have to do all the
time. We have to pick and choose which resident we have to take
care of first. And it is a challenge for the nurses and for the
CNAs that we deal with every day.
Senator Brown. Thank you for that good, concise answer.
Throughout COVID, higher nurse staffing levels have been
associated with fewer COVID-19 cases and deaths. We know that.
I have introduced legislation in this committee to require
hospitals to maintain safe staffing levels. And I know Chairman
Wyden wants to do this and consider ways to improve nurse-to-
patient staffing ratios at long-term care facilities.
My last question, Ms. Ramos--I notice your T-shirt, and I
know you are a proud member of the Service Employees
International Union. Talk to me about how being part of a union
has allowed you to better advocate for your patients.
Ms. Ramos. Being part of my union helps me advocate for and
be a voice for the workers who do not have a union, and the
patients who do not have the family members who will stick up
for them.
And we do that across the country. And also, when we are
united and we have power--so with that power, we got hazard pay
during the pandemic. And to make our voices heard and really
inspire change, that is the reason why I am here today telling
you our stories in a nursing home.
Senator Brown. Thank you, Ms. Ramos. Thanks for your
conciseness.
Mr. Chairman, my time has expired. Thanks very much for
having this hearing, Chairman Wyden.
The Chairman. Thank you, Senator Brown.
Our next--we've got Senator Cardin back; wonderful.
Senator Cardin. I think I am with you now. We changed the
connection.
The Chairman. Perfect.
Senator Cardin. Thank you very much. First, thanks for this
hearing. It is very important.
Ms. Ramos, I want to thank you and all the front-line
workers for what you have done during COVID-19. You truly have
stepped up to help our community, and we thank all of our
front-line workers during this time.
It has been very challenging. We know of the circumstances
when personnel become difficult because of getting COVID-19,
and protecting our workers, and protecting the residents at
nursing homes. It is a real challenge.
We recognized this before COVID-19. And that is why we
looked at the issue of infection prevention in nursing homes.
In 2016, the Obama administration issued certain regulations in
regard to the requirements for nursing homes. The Trump
administration reduced some of those requirements.
I guess my question to you is, do we have adequate Federal
guideline protection to deal with ongoing issues of infectious
diseases? Look, COVID-19--we will get beyond that at some
point--but there are going to be other issues that are going to
come up that affect the health of the nursing home residents
and the personnel who work in nursing homes.
Are we doing enough as far as Federal guidelines to require
nursing homes to have adequate protection to deal with
infectious diseases? Whoever wants to answer it, I welcome your
thoughts.
Mr. Dicken. This is John Dicken with GAO, and I can just
note that certainly even making the point that you made is
important, that even before the pandemic we found that the
highest source of deficiencies that were found in nursing homes
was for infection control.
And so it is essential that there be focus even outside of
this pandemic environment on trying to control and prevent
infections, and to apply appropriate infection control
practices. That is a requirement: that the nursing homes have
plans to be able to prevent and control infections. Even before
this pandemic, that was the primary type of deficiency that was
found in nursing homes.
Senator Cardin. So I guess my question to all of us is
that, obviously, a lot of this can be done administratively,
but we in Congress might need to take a look at policies that
reflect that.
One of my interests is how we share best practices. We know
that nursing homes have come up with creative ways to protect
their residents, and to protect their essential workers. Is
there an adequate communications system within the nursing home
industry itself to implement the best practices that are being
used around the Nation? And is there a way that the best
practices can make their way to us policy-makers so that if we
look at legislation, we look at what is working and what is not
working and try to develop the best policies for our country?
Again, I welcome anyone on the panel who wants to talk
about that, as to how we can take the best practices that are
being used today to keep nursing home residents safe, and the
personnel safe, and how we can implement that in Federal
policy.
Ms. Ramos. This is Adelina. From my experience, we need to
have oversight in the nursing homes. And the Senate is the only
one that can do that.
We tried working on it through the State to have a law
passed so we could have safety and better quality care for our
residents, because before the pandemic, like you said, we had
this problem. And with the pandemic, it made things worse.
So it is not just a State-by-State problem, it is across
the whole country. Because my story is not unique. If you ask
anybody else in any other States, they have similar stories.
They have seen similar things, or worse, of what I have been
through.
So I think Congress has the power to change the laws across
the country.
Senator Cardin. And I think the SEIU can play a major part
in that. You have people around the country who have seen what
works well, and what has not worked, and I think sharing that
information with us would certainly be very helpful as we try
to deal with this issue moving forward.
We have to look at the lessons learned as a result of
COVID-19, recognizing that infectious disease spread within
confined nursing homes is going to be an ongoing challenge in
regards to the safety of people in this country.
Thank you, Mr. Chairman. I thank our witnesses.
The Chairman. Thank you, Senator Cardin. Next will be
Senator Lankford, and then Senator Casey, and I hope we can get
both of them in. We have a vote going on.
Senator Lankford?
Senator Lankford. I will hustle, Mr. Chairman. Thank you
very much for doing that. I have been a very outspoken advocate
for, obviously, safety in facilities, in all of our long-term
care facilities, as all of you have been as well. So I
appreciate very much what you are doing for this.
But I have also been an advocate to say many individuals in
my State--in fact, all the individuals who want it in my
State--who are in long-term care facilities have already been
vaccinated, both the staff and the individuals. Some of them
were vaccinated 5, 6 weeks ago and have been through the full
regimen and been on the other side of it.
There is a difficult balance there of trying to provide
safety to those individuals, but also to have access to their
grandchildren, their families, and other individuals, school
groups that want to be able to come in and bless them.
What they have seen is some normal activity in the past
around the facility in trying to strike that balance. CDC has
put out some guidance. States, including my own State, have put
out some guidance on their own. Sometimes they are not lining
up.
So my question on this is, based on where we are right now,
what would you recommend that we put out as guidance for
individuals who are dealing with real depression and real
isolation in a very difficult season of life already? What
would you recommend we start to do right now for those who have
already been vaccinated in the facility? So I open that up. Dr.
Gifford, obviously you are going to be the obvious one on this,
but I would open it up to anyone else who wants to be able to
respond to that as well.
Dr. Gifford. Well, I think--I am glad you are raising that
point. And I think we have all seen--the families and health-
care givers--that when you take a frail elderly person and
restrict them from seeing their family, and they cannot
participate in activities with the other residents, and really
have trouble interacting with the staff as well because many of
them have dementia and they do not understand what is going on,
it will have dire consequences with them.
And I think the challenge is when you balance the safety of
a virus that has a 20-percent mortality risk with the clearly
devastating impacts you have had with that. I think we are
transitioning out of that, which is good.
I think this raises just a broader question about how do we
move to provide the care, activities, and infection control
when you have to restrict people's movements around in a
building?
Senator Lankford. Other comments from other individuals?
Ms. Ramos. Yes, please, I would like to add to that. I
think in large part, on the temporary nurse aides, and how
people have gone and gotten the certification to be able to
work in facilities but may not have all the credentials, I
think from a logistical standpoint, just simply put, we could
allow families to take the same type of training for infection
control and universal precautions and allow for the designation
of essential caregivers, so they are able to be in there, and
able to come in and help supplement the care the staff may not
be able to provide.
A lot of these people were going to see their families
weekly prior to COVID, and so I think it is just one of many
solutions that we could look at across the board. And you know,
in working through that, they would still be held to the same
requirements as staffing in terms of testing and, ideally,
vaccinations.
Senator Lankford. Do others want to be able to comment on
that?
Dr. Konetzka. I will just add that the essential caregivers
programs that were just mentioned, a handful of States at least
implemented these even before the CDC opened up guidance about
visits. And those may serve as a model, as a good model for how
we should be moving as a country. Those are programs in which
some family members could go in on a regular basis, and they
took all the precautions that staff took, and I think those
were generally very successful.
Senator Lankford. So would you recommend something like
this in--let's skip past COVID. We are all looking forward to
that day. We are past it. In whatever that looks like for us,
we will still have tough choices in the days ahead. And
obviously, a really difficult flu can have a catastrophic
effect inside of a long-term care facility as well.
Would you recommend some of these same processes be carried
over into a difficult flu season as well, for individuals in
long-term care?
Dr. Konetzka. Perhaps. But I think it is important to
remember that reducing physical risk is not the only goal here.
We need to find the right balance between quality of life and
seeing family and friends, and reducing physical risk. I think
the goal is probably not zero risk; the goal is to find the
right balance.
Senator Lankford. I am glad to be able to hear you say
that, because there does seem to be a concern about how we get
to zero risk. And zero risk has a lot of emotional damage on a
lot of families, and a lot of individuals in their isolation.
And some of the individuals that I interact with will say
things like, ``I have been waiting for 10 months, and I've
thought in my head over and over, once I get the vaccine this
will be different.'' And they are experiencing right now
nothing different for them, and they have had the vaccine.
So they are trying to find some hope in the middle of this
as well. So thank all of you for the ongoing work that you have
done.
The Chairman. Thank you, Senator Lankford.
Senator Casey--and, colleagues, Senator Casey has done
three separate reports on this issue. He has put an enormous
amount of effort into it, and we appreciate it. Senator Casey?
Senator Casey. Mr. Chairman, thank you very much for having
this hearing. I want to thank you and the ranking member. And,
Mr. Chairman, I want to thank you for the work you have done to
hold the prior administration accountable on these issues that
relate to nursing homes and long-term care, and to work with me
and with others to move this agenda forward, which we still
have much work to do in connection with. I am just grateful for
this opportunity. Senator Whitehouse earlier, in his
introduction of Ms. Ramos, was highlighting some of the work
that he has done with us as well, and we are grateful for that.
I want to start by offering at least, at a minimum, words
of commendation to Ms. Ramos and other front-line workers. In
your testimony very early on, you talked about, quote, ``days
filled with fear and sadness'' in the work that you have done.
And we want to commend that work.
I was especially moved by the reference you made to when
you had contracted the virus and were not able to hug your son
as you would want. And so many Americans have felt the same--
that same sense of loss.
And the moment you talked about sitting with a long-term
care resident and wanting to hold her hand, but being pulled
away to the work that you had to do because of staffing
issues--so we want to thank you and SEIU for standing up for
workers like you.
We have to do more than offer words of commendation. We
have to start voting with you--both parties, both Houses, both
branches of government--to lift up the caregiving workforce. We
are decades late in doing that. And so, I do not ask for your
comment, I just want to let you know that we are thinking about
you and realize that we have an obligation to you and those
with whom you work.
My question will be preceded by a little bit of background.
I want to direct my question to Dr. Konetzka. We know that, as
many of us have referenced, now more than 178,000 residents and
workers in long-term care have died from the COVID-19 virus.
This is a terrible, profound tragedy within the broader
COVID-19 tragedy. We know that, in Congress, we have an
obligation to learn from the tragedy and to deliver a common-
sense response.
I worked with Senator Toomey, my colleague from
Pennsylvania, on work we did in connection with the Special
Focus Facility program. We did some investigative work and made
some changes, but now we have legislation that we have just
recently reintroduced: the Nursing Home Reform Modernization
Act.
It does basically three things. Number one, it expands the
oversight of the Special Focus Facility program's Candidate
Facility--that is a specific type of facility. Second, it
increases the educational resources for the facilities that are
underperforming. And third, it establishes an independent
advisory council to inform Health and Human Services on how
best to rank nursing home performance and foster quality
improvements. I am grateful to be working with Senator Toomey,
because some of this work can be and must be bipartisan.
Dr. Konetzka, do you think that there is merit in expanding
the size of the Special Focus Facility program to more
facilities and enhancing the oversight of underperforming
nursing homes?
Dr. Konetzka. Senator Casey, first of all, thank you for
your persistent efforts on the issues of nursing homes and in
the area of disparities. I am fully supportive of your efforts
to expand the Special Focus Facility program. We all know that,
even though there are many nursing homes that provide very good
quality of care, there is a bottom tier of nursing homes that
are chronically problematic. And that is the tier of nursing
homes that the Special Focus Facility program is aimed at.
It has been a tiny program over the years, and I think you
are absolutely right in wanting to expand that program and
doing what we can to try to bring up that bottom tier.
Senator Casey. Thanks very much, Doctor. And I know that we
have about 30 seconds left, but just to ask quickly, Ms.
Bottcher, with regard to transparency. I will just make it
quick, without a prelude, to ask, what do you think we have to
do to give families what they need to make informed decisions
about nursing homes?
Ms. Bottcher. Well, of course knowledge is power. And so,
having transparent data available for families, making it easy
to read, being consumer-friendly, that will go a long way to
helping families understand what is going on with their loved
ones.
Senator Casey. We look forward to working with you and the
rest of the panel.
Thank you very much, Mr. Chairman.
The Chairman. Thank you for the good work, Senator Casey.
Senator Grassley?
Senator Grassley. Thank you, Mr. Chairman.
Since we are talking about nursing homes, I think I ought
to start by saying ``thank you'' to every American who has
supported our seniors during this pandemic, because our nursing
homes house the most vulnerable that we have in our society.
And this has been a very challenging year for these seniors,
but it has also been a very challenging year for our health-
care workers.
Before I get to my first question for Mr. Dicken and Ms.
Moten, let me lead in with this. Last year, the Department of
Justice launched an investigation into four States' COVID-19
responses in nursing homes. These States were Michigan, New
Jersey, New York, and Pennsylvania. They pressured nursing
homes to admit residents who may have been infected with COVID-
19. The CDC recommended that hospitals discharge patients with
COVID-19 diagnosis only to nursing homes that are capable of
implementing all recommended infection control procedures.
State officials who pressured nursing homes to admit
untested or contagious COVID patients from hospitals likely
increased the case rate and fatality risk for these residents.
Meanwhile, State officials in other parts of the country--
Florida is just one example--followed CDC's guidance, often
with better results.
So to Mr. Dicken and Ms. Moten: how important is it for the
Department of Justice to continue investigating these four
States' violations of the civil rights of the nursing home
residents and the failed duty to care?
Mr. Dicken. Thank you, Senator Grassley, and I appreciate
your long-term leadership on these issues. Certainly what we--
we are aware that there are both Federal and State-level
investigations ongoing. GAO continues to examine what the
experience has been across all States, as this has affected all
States. And there are two key points on that.
One, one reason why GAO has recommended that there needs to
be more complete information that was only voluntarily reported
at the Federal level on cases and deaths in nursing homes prior
to May, is so that we can learn some of the lessons that we
learned from the very uncertain and challenging times early in
the pandemic.
And secondly, we have talked to--our ongoing work looks at
a range of States across the country, and we are hearing common
concerns about how best to get protective equipment, dealing
with protecting hospitals. And these are challenges that have
been faced throughout the country.
Ms. Moten. I want to echo the sentiments of Mr. Dicken. I
think that it is important that we continue to investigate
these four States in particular, and States across the country,
as we are able to take those stumbling blocks and make them
stepping stones.
You know, the reality is that we could have done a better
job in a lot of these places. And while oftentimes our care
community mirrors what was going on in other communities, our
hospitals were able to handle infection control. And so I think
we need to look into this so that we are able to figure out
what system breakdowns we had in those different States and
better understand them, so we do not repeat those same
mistakes.
Senator Grassley. Both Republican and Democrat Senators
have warned President Biden that he should not terminate 56
U.S. attorneys, particularly those who have ongoing sensitive
investigations.
One is Toni Bacon, the U.S. Attorney, Northern District,
New York. Ms. Bacon previously served as the Justice
Department's National Elder Justice Coordinator and currently
has jurisdiction over Federal public correction crimes in the
State. The State of New York under-counted nursing home deaths
by as much as 50 percent, and State officials intentionally
withheld data for months. Ms. Bacon is the obvious choice to
continue a fair and unbiased investigation into possible
violations of civil liberties of the elderly and public
corruption.
So, to the same two people, Mr. Dicken and Ms. Moten, do
you believe the U.S. Department of Justice must have a fair,
unbiased, and experienced U.S. Attorney in the Northern
District of New York, such as Ms. Bacon?
When you get done answering, I will have to say my time is
up. But let's hear the answer.
Mr. Dicken. Thank you, Senator Grassley. I cannot speak to
the specifics there, but I certainly know that there are fair
and complete investigations at the Federal and State levels.
But I have not looked at that specific situation.
Senator Grassley. Ms. Moten?
Ms. Moten. Again, I echo Mr. Dicken's position on that. I
think that an unbiased party is definitely going to be needed
to make the proper recommendations and to do a full
investigation. But I cannot speak to the person you are asking
about.
Senator Grassley. Thank you, Mr. Chairman.
The Chairman. Thank you, Senator Grassley.
Just one fact, quickly, before we go to Senator Menendez.
When you look at the top 10 States with the highest number of
COVID deaths per occupied bed, they are evenly split between
States led by Democratic and Republican Governors, which
supports the proposition this was not a blue State/red State
issue. It is a huge national tragedy for the country.
Senator Menendez?
Senator Menendez. Thank you, Mr. Chairman.
Mr. Dicken, last June I led my House and Senate colleagues
in a letter to then-Secretary Azar, and then-Administrator
Verma, pleading for more resources, guidance, and support for
nursing homes. At the time, New Jersey had already been on the
front lines of the pandemic for over 2 months--2 months when we
were fighting in the dark against an invisible enemy; 2 months
when New Jerseyians suffered immeasurable losses and pain.
In that letter, I called for a comprehensive national
testing plan. We did not get it. I asked for a strategy to
ensure our nursing homes had sufficient PPE. I asked for a plan
on staffing shortages, and how to care for COVID-19-positive
residents. And I called for greater resources to improve
reporting and communication.
We did not get all of those things. And when we did get
something, it came slowly and, for many, too late. So that we
can learn from the past, can you talk to us about the harm
inflicted by the failure to put in place a national testing
plan last spring?
Mr. Dicken. Yes; thank you. And right, that is part of the
broader work in the Federal response to the pandemic. GAO has
also recommended that there be a national testing strategy, and
that has not yet been implemented.
That is key for several reasons. The national testing
strategy would help better target information on what resources
and expertise can be used to try to control or prevent
outbreaks. It also could ensure more consistency, so that
State, Federal, and private entities work on common goals, and
that there would be common information that could have more
transparency.
Senator Menendez. Thank you.
Dr. Gifford, I recently introduced the PREPARE Act and sent
a letter with Congressman Pascrell to the administration
requesting that infection control practices be improved in
nursing homes to combat the future spread of COVID and other
viruses.
Your plan also calls for a new focus on infection control
by adding additional requirements to the infection
preventionist position that is required in all facilities.
Could you elaborate on your plan and how these changes would
help provide a healthier environment for the residents you
serve?
Dr. Gifford. Thank you, Senator Menendez, for all of your
efforts on both PPE and infection control. We definitely have
supported the infection preventionist program and requirements
since the beginning. I think what we have learned is that you
need to tailor that infection preventionist to the needs of the
facility.
A large facility with 300 to 400 beds needs more than one
person. A 20-bed facility in a rural community does not need
the same amount. A facility that takes care of highly acute
illness, and very sick individuals, may need more infection
preventionists than those that have less acuity in there.
And so we would strongly support it being evidence-based.
You also do not want to say it has to be one person, because if
that person gets sick or is out on vacation or not working
those days, you want to have good coverage on infection
prevention throughout. So this should be covered by multiple
people.
So we are asking for an evidence-based approach to
addressing this infection preventionist in a nursing home.
Senator Menendez. And one final question. Last week, the
AHCA sent a letter to the administration asking for next steps
for vaccinations at nursing homes. Now last week, we learned
that in New Jersey only about half of our nursing home staff
are vaccinated. Since the pharmacy partnership with retail
pharmacies and nursing homes is drawing to a close, it seems to
me we need to be sure we can still get people vaccinated in
these facilities.
What are some of the more creative ways the Federal
Government can partner with our nursing home partners to reach
the stated goal of 75 percent of staff vaccinated by June 30th?
Dr. Gifford. Well, I think the initial plan they had,
working with retail pharmacies and getting the vaccine out
there, was a highly successful program. I think the challenge
now is getting vaccine out. There just is not enough vaccine
still coming out and being allocated into the program. And so,
no matter how innovative a program you have, there is no
vaccine being allocated out, other than for a handful of
States.
We need to not let the gains that we have seen with
vaccinations slip. It is also clear, I think as you heard from
Ms. Ramos, that you need to have multiple people sitting down
and listening and talking to staff and residents about what
their concerns are with the vaccine, so that they can
understand what is going on out there. And CDC is sort of
working in that area, and we support that effort.
Senator Menendez. Thank you, Mr. Chairman.
The Chairman. I thank my colleague. We are going to keep
this going. Senator Crapo has been kind enough to say he will
run the hearing while I run and vote. And I think I saw Senator
Hassan. Perhaps she will be back soon.
Senator Crapo, if you will run it, I will be back very
quickly.
Senator Crapo [presiding]. I will do so. Thank you, Senator
Wyden.
Do we have any Senators who are here at this time? Senator
Thune?
[No response.]
Senator Crapo. Senator Barrasso?
[No response.]
Senator Crapo. Senator Warren?
[No response.]
Senator Crapo. Senator Hassan?
[No response.]
Senator Crapo. Well, if no Senator shows up, I will go back
into some of my questions. Hold on a minute while I grab my
stack of papers here.
All right; thank you. I am going to go next to you, Ms.
Bottcher. You put in your testimony--you have outlined a five-
point plan or a proposal that you are focusing on. I was
interested--well, I was interested in all of those points. Your
third point was basically to focus, if I understood it
correctly, on safe access to in-person and virtual meetings
between nursing home residents and their families.
Could you expand on that a little bit? Are you saying that
we need to increase in-person, or just make sure that we focus
both on in-person and virtual?
Ms. Bottcher. So, both in fact. And thank you for the
question, Senator Crapo. AARP has advocated, when it is safe to
do so, to allow for in-person visitation. And of course CMS
updated those guidelines. But in-person visitation--we cannot
lose sight of the fact that we still have to talk about
infection control and follow those procedures.
There still has to be adequate staffing to be able to
provide and support in-person visitation and all the other
guidelines that CMS has put forward--and so all of that. It is
a delicate balance, as we have talked about. In-person
visitation would certainly help those who have had some mental
decline without that social connectedness. And it would help
with the mental health of the person, but we also have to do
everything we can to provide for the safety of that person with
regard to COVID.
Insofar as virtual visitation goes, we believe that
Congress could do more to require that facilities facilitate
virtual visitation when they cannot support in-person
visitation. And of course we saw that throughout the pandemic
with the use of cell phones, with the use of iPads. But this
was not done consistently throughout nursing homes across the
Nation.
Senator Crapo. Thank you. I was just about ready to go to
you, Dr. Konetzka, but I see that we may have Senator Thune
with us. Do we? And if not, I do see Senator Daines.
Senator Daines, you may proceed.
Senator Daines. Right. Thank you, Senator.
Well, I am glad to be part of this hearing today. This is
something that has touched Montanans deeply. Over the past
year, our Nation and my own State of Montana have experienced
loss in so many ways. Our seniors have borne the brunt of this
pandemic, in fact, so much so that States like New York have
tried to cover up the true toll this pandemic has taken on
nursing homes.
The reality is that more than one-third of all U.S. COVID-
19 deaths are linked to long-term care facilities. We must do
more to support our nursing home residents, many of whom have
suffered with increased depression, anxiety, and worsening
dementia due to COVID restrictions, and the isolation.
Throughout the pandemic, residents were deprived visits
from sons, daughters, new grandbabies, staring through windows,
listening to recordings of loved ones to try to keep those
memories alive. And we know that extreme social isolation can
have very serious health consequences and can even be deadly.
With nearly two-thirds of seniors having received their
first shot, and millions of American being vaccinated every
day, we are finally turning the corner. There is hope. Today,
nursing home residents across the country can visit safely with
their loved ones, and we have even seen examples of hugging
their family members for the first time in a year.
We are making great strides. We are getting shots in arms
across the country, currently at a pace of over 2 million per
day, but there are folks who are reluctant to get the vaccine.
A February study by the CDC estimated low rates of vaccine
uptake among nursing home staff at 38 percent, compared to
nursing home residents at 78 percent. We need at least 75
percent of the population to be vaccinated for us to achieve
herd immunity and get back to normal.
I decided to take part in the 5-year vaccine trial last
year--it was offered in my home town of Bozeman, MT--because I
want to do my part in helping to make Montanans feel confident
about the vaccine.
My first question is to Mr. Dicken. Can you describe how
well vaccine distribution in nursing homes is going and provide
any analysis on the CDC's study on vaccine uptake?
Mr. Dicken. Yes; thank you, Senator Daines. And you are
right that as nursing homes have been prioritized for vaccine
distribution, more than 99 percent of homes that participate in
the Federal partnership have had at least one on-site clinic
that could help offer vaccines to residents and staff.
That is more than 4.25 million vaccines that have been
distributed to residents and staff in nursing homes as of early
February. And that number continues to grow.
Senator, the CDC numbers you cited are correct that have
had a larger share of residents who have taken the opportunity
to get the vaccinations, and that during the first clinics that
occurred under the partnership, a smaller share of staff had
agreed to take the vaccinations.
There was hope that over time, as there continued to be
more opportunity and clinics, that would increase. The comment
that my fellow panelist, Ms. Ramos, her experience--as more
staff see other colleagues who have been vaccinated and the
decline in cases, we can only hope that that would increase
their comfort with receiving vaccinations.
Senator Daines. Thank you.
I have a question for Ms. Bottcher. Last year I teamed up
with Senator Grassley on a bill that would allow for the
creation of strike teams in States to help facilities that were
being overwhelmed by COVID-19. This bill also supported tele-
visitation programs so that nursing home residents would not be
as isolated from family in the stresses of the pandemic.
Ms. Bottcher, can you speak to the benefits of virtual
visits in lieu of in-person visits, and what barriers prevent
residents from accessing tele-visit technology?
Ms. Bottcher. Certainly. Thank you so much for the
question. AARP has long been supportive of virtual visits. And
we have--when the pandemic unfolded and nursing homes were
closed, families were shut off from their loved ones. And a lot
of them did not already have that set up with their loved one.
And so it was incumbent upon nursing homes to facilitate
that to the best extent, where they could. I think the
shortcomings were the infection rates. As they rose in
facilities with residents and staff, then you did not have
enough staff to facilitate those virtual visits. You had some
nursing homes that were concerned about passing around the
technological devices to be able to facilitate that.
So there just was not a lot of support to be able to do
that. So families were then troubled and became desperate. We
heard from several families who were so desperate they would go
to every single window around the nursing home and just start
knocking until they found someone that they could talk to to
wheel their loved one to the window. And they would call us
just in frustration.
Some nursing facilities do not have strong broadband
connection, or lack Internet access. That is also a problem
that needs to be addressed.
And so, the extent to which we can require nursing homes to
provide virtual visitation in lieu of in-person visitation when
that cannot happen, that should be done.
Senator Daines. Thank you. I see I am out of time.
Thank you, Senator.
Senator Crapo. Thank you, Senator.
Senator Warner?
Senator Warren. Was that Senator Warren or Senator Warner?
Senator Crapo. Warner.
Senator Warren. Oh.
Senator Crapo. I am sorry. Wait your turn. [Laughter.]
Senator Warren. Sorry, Mark.
Senator Warner. Thank you, Senator Crapo.
I want to--I have a couple of questions here. One, I want
to start on the question of nursing home staffing. This is an
issue I have been working on with Senator Tim Scott. We have to
make sure--and obviously COVID has shown the ability of the
facilities to recruit and retain quality staff is a challenge.
It is oftentimes low pay. Part of that is due to the
reimbursement rates, meaning the margins are quite thin for
these facilities. And obviously post-COVID, I think this
problem was only exacerbated.
I am going to start with Ms. Ramos. As a nursing home
worker, could you talk a little bit about this issue and give
any advice you might have on how we can better recruit and
retain nursing home workers? And, Dr. Gifford, from the
Association's standpoint, can you speak to this issue as well?
Ms. Ramos. Hi; thank you for your question.
So like I said before, the quality of care and the short
staffing had been issues before the pandemic. So the pandemic
made things worse. For us health-care workers in the nursing
home, it is a big challenge. Most of the time, we have 13 CNAs
to 12 residents who are total care. So when you have that
amount of residents per CNA, a lot of them stay in bed for long
periods of time. And when the family members were coming in to
visit, they were getting very upset, because they would come at
10:30 a.m. and their loved ones were in bed. So they would
complain.
But as the pandemic hit, we were still working short, and
as things got worse, we were lucky that we had a union that
backed us up. And then we have complained for the ones who
cannot speak for themselves, like our patients in the
Alzheimer's unit. Our union supports us to speak up for them.
So with the pandemic, things got worse. And it is worse in
the nursing home. We are still working short-staffed all the
time, and our residents are not getting the quality care they
deserve.
Senator Warner. Dr. Gifford, did you have a comment?
Dr. Gifford. Yes. I think, as you heard from all the
panelists today, the workforce needs to be improved. And we
need better ways to recruit and retain. I think you have heard
from us all today that, as you recognized, the tone of this is
due to the underlying funding.
You know, the other challenge is, how do we recruit and
retain beyond just the salaries? I think loan forgiveness
programs are something we have been championing and we really
need help with. That would go right to the workers. Tax credits
for people who work in this sector. Subsidies to schools and
technical schools to have their graduates working in long-term
care.
What we have seen in many of those programs is students get
sucked up by the hospitals and work elsewhere, and they do not
come to work in long-term care. So we need to have specific
programs that make us a priority. I mean, I think the one
biggest lesson learned from this--and you heard it from
everyone--is we were not a priority. So if we are going to make
staffing a priority, we have to make loan forgiveness, tax
credits, incentives to schools, a priority to get workers into
long-term care. Otherwise, they will work in the other sectors.
Thank you.
Senator Warner. And let me just add, I stand with, I think,
all our colleagues in a bipartisan way that we need to weed out
the bad actors in this space. The star rating, I think, has had
mixed success. But I also know from just a business
perspective, the reimbursement rates are so low, and the
margins are so thin, that those nursing homes that are trying
to do the right thing--and I am particularly concerned now when
we have seen nursing home populations, perhaps appropriately
after COVID and people's concerns, fall 20, 25, 30 percent. I
am not sure what the business model is going to look like,
particularly in rural communities, so we can keep these
facilities open with a level of quality where folks like Ms.
Ramos can have adequate staffing.
Dr. Konetzka, could you--I know you have done a lot of
research on this, including reimbursement rates. How can we
make sure that the good operators are still able to operate,
and how are we going to grapple with this issue of, in rural
communities, 20-, 25-percent decrease in patient population?
What is the model that is going to make this work?
Dr. Konetzka. That is an excellent question, but it is a
really hard one. This is the hard challenge to answer, right?
Because it is almost definitely going to take resources. I
think we generally underfund long-term care in this country. I
agree with you that Medicaid rates in many States are very low,
probably too low to take care of the level of need in a nursing
home population.
I think, moving forward, we have to think about fundamental
changes to the system. I think that there is an aging capital
stock of nursing homes. There is financial fallout from the
pandemic. And there are chronic problems such as under-
staffing.
So I think we need to take a hard look at the underlying
payment mechanism and the funding we inject into the system,
and perhaps consider some bold changes.
Senator Warner. Thank you, Mr. Chairman. I know Elizabeth
is, I think, next----
Senator Crapo. Unfortunately, Senator Thune came back. So
it is going to be Senator Thune next. Elizabeth, we are getting
there.
Senator Thune?
Senator Warner. Famous last words there. [Laughter.]
Senator Thune. Thank you, Mr. Chairman. Let me just say
that the subject of today's hearing is one that I think we all
wish we were not having to discuss, with the stories in our
States----
[Loss of audio.]
Senator Crapo. Senator Thune, have you been muted?
Senator Thune. Am I on? Hello?
Senator Crapo. Hello; we can hear you now.
Senator Thune. Can you hear me now?
Senator Crapo. Yes.
Senator Thune. You have me? Okay. All right. Well, I will
skip the preamble there----
[Loss of audio.]
Senator Crapo. John, I think we are having trouble with
your signal. We will give it about another 5 or 10 seconds, and
then, Elizabeth, I think I am going to have to--oh, here he
comes. Can you speak, John, and tell us if you can hear us?
[No response.]
Senator Crapo. All right, Elizabeth, why don't you go?
Senator Warren. All right; thank you, Mr. Chair. And I am
sorry, Senator Thune, but I am sure we will get this
straightened out.
When the coronavirus hit, nursing homes were ground zero.
Today, at least 34,000 nursing home residents and 1,600 staff
members have died of COVID-19. Responding to coronavirus is
challenging for every health-care provider.
Genesis HealthCare, a nursing home chain with over 350
facilities across the country, was one provider that struggled.
Ms. Ramos, you work at Greenville Nursing Center, a Rhode
Island nursing home owned by Genesis. From your testimony, it
sounds like working at a facility last year was harrowing. Let
me just ask: did you have the resources and the staff you
needed to properly care for COVID-19 patients?
Ms. Ramos. Thank you for your question. No, we did not have
enough resources or the staff that we needed. But those, like I
said before, are not new issues. Sometimes we have two
residents with serious needs at the same time, but we have to
choose who deserves our care. And every one of them deserves
our care, 100 percent. But it is sad that we have been put in
that situation all the time.
Senator Warren. And you are right: it is sad to be put in
that situation. But basically what you are saying is that you
did not have the supplies, you did not have the staff you
needed when the coronavirus hit. And I know that a lot of the
nursing homes around the country were in the same boat, which
is why Congress passed COVID-19 relief packages like the CARES
Act earlier to get providers the resources they needed.
Now in January, I wrote to Genesis, which owns the nursing
home where you work, and I received information that shows that
they accepted $665 million in State and Federal grants and
loans last year. And guess what Genesis did? It gave its then-
CEO an approximately $2-million retention bonus just a few
months before he left the company, which was and is in dire
financial condition. In total, the CEO, George Hager, has
received $8 million in compensation since January of 2020.
Ms. Ramos, you told us about how one of your co-workers
died while trying to care for COVID-19 patients, while working
at a facility with a $14 an hour starting wage. So let me just
ask you your view on this. Should a top corporate executive
have received a multi-million-dollar bonus while you were
struggling to keep patients alive and keep yourself alive?
Or let me ask it another way. What could have been done to
improve patient care with that $5.2-million retention bonus
that the CEO received?
Ms. Ramos. No, I do not think they should make millions of
dollars in bonuses, because it is Medicare money. That money
should be going to patient care.
So with that $5 million that he received, we could have
paid a higher wage so we could attract more staff.
Senator Warner. Right. More staff. More PPE. And that is
exactly what Genesis should have done. It should have invested
in workers like you.
So let me ask you, Dr. Gifford--you are here on behalf of
the American Health Care Association, which represents nursing
homes. Do you think it is right that nursing home CEOs received
multi-million-dollar bonuses, while workers like Ms. Ramos
fought for more PPE, more tests, and more resources?
[No response.]
Senator Warren. Dr. Gifford?
Dr. Gifford. Senator, as a medical director, having worked
in nursing homes in Rhode Island, I did not have the pleasure
of working with Ms. Ramos there, but I saw firsthand--as you
pointed out and Ms. Ramos has--how hard the CNAs work relative
to everyone else. And they are really the lifeblood of an
organization.
I think early on in this pandemic there was not PPE
worldwide anywhere. And we were hearing from every type of
facility out there about the need for getting PPE, and getting
staffing. And we were calling for it. And what was available
was not prioritized for nursing homes. It was going to
hospitals and elsewhere. And I think the idea of how we
prioritize and use that--the PRF funds that came to us were
lifesaving. Many of the nursing homes out there are small
family-run nursing homes, second and third generation----
Senator Warren. So, I am sorry to interrupt, but that was
not my question. My question was whether or not nursing home
executives should be paid multi-million-dollar retention
bonuses, or whether or not those millions of dollars should be
invested in the resources that are needed to keep staff and
residents safe and healthy.
Dr. Gifford. I think that is a good question, to think
through how compensation is done at all levels and how are we
going to be able to compete for retaining and recruiting staff
at all levels throughout the health-care system. And that is
something that we will need to look at. And I think we are
fully supportive of transparency regarding how these funds were
used going forward.
Senator Warner. Well, I appreciate that you are going to
look at it, but I just want to be clear on this. We cannot
allow corporate greed to determine whether or not workers and
seniors in this country live or die.
That is why I wrote to Genesis requesting information about
their financial decisions. And today I am going to release
their response, which comes in the wake of reports that Genesis
will soon be under private-equity ownership.
I will be opening an investigation into for-profit nursing
homes, including those run by private-equity firms. And the
next time there is a pandemic, seniors should not be stuck in
sub-par institutions run by greedy CEOs and vulture firms in
order to make a quick buck.
Commerce needs to act now before tragedy strikes again.
Thank you.
Thank you, Mr. Chairman.
Senator Crapo. Thank you. And, Mr. Chairman, I see you are
back. Senator Thune, I believe, is next.
The Chairman. I believe that is right.
Senator Thune?
Senator Thune. Thank you, Mr. Chairman. Can you hear me
this time?
The Chairman. Yes.
Senator Thune. All right; we are back. Well, I appreciate
the subject of today's hearing. Obviously it is a huge issue
during the pandemic with a lot of nursing home residents
isolated and unable to see their families, and with quality of
care and staffing issues that this committee has looked at.
This committee has, before the pandemic, and now more than
ever, we need to address these issues to ensure that everyone's
loved ones receive the care that they deserve.
Dr. Gifford, I understand at this time facilities are not
required to report to CMS on staff and resident vaccination. Is
there no CMS mandate or standard? How are your member
facilities keeping track of vaccination records? And I am
thinking about this in the context of future follow-up care
once we know more about the longevity of COVID vaccines, or the
need for boosters over time. So if you could address that.
And then, Mr. Dicken, is there anything GAO is recommending
on reporting vaccinations in nursing facilities?
Dr. Gifford. Senator Thune, you are correct that currently
there is no requirement. All the facilities are tracking
vaccinations rates on their staff and residents internally.
There is a portal at the Centers for Disease Control called
NHSN where you can report staff and resident vaccination rates.
And we have been strongly urging our members to report that. We
have been urging CMS and other entities to help sort of move
that along. And we are fully open to transparency and having
the information revealed out there, just for quality
improvement purposes, as well as for family and residents.
We have also set a goal of getting 75 percent of the
residents vaccinated. And we need that information to see how
we have achieved that goal. So we are very supportive of that.
Thank you.
Senator Thune. Okay.
Mr. Dicken, is there anything GAO is recommending on
reporting?
Mr. Dicken. Yes; thank you, Senator Thune. And certainly
GAO is continuing to track vaccine distribution, as well as
efforts to assure that residents and staff and homes are
offered vaccines, and to what extent that information is
available and transparent.
I would note that there are other models in the nursing
home setting. There is reporting now of vaccinations for flu or
pneumococcal, and so certainly GAO has continued to track the
experience in nursing homes in the current environment of
COVID-19. GAO is continuing to track that and the efforts to
make sure that there is data available, and that that can be
made available, including at facility levels.
Senator Thune. Okay; thank you.
Dr. Gifford, as we work to solve quality-of-care
challenges, we also need to be mindful that access remains a
priority as our population continues to age.
You testified the nursing home industry projects up to
1,600 closures in the aftermath of the pandemic. I expect
census declines and COVID-related costs contributed to this.
Could you shed further light on the causes of these closures,
and if you can, project where in the Nation we might be at risk
for closure? And of course, I am thinking particularly where I
come from, like rural areas.
Dr. Gifford. Senator Thune, I think you are going to see
the challenges, because the census in the facilities has
dropped precipitously, from a little over 80 percent to under
70 percent. It has been about a 15-percent drop. That is not
sustainable.
And so I think, particularly in the rural areas and their
smaller facilities, they are more at risk. I think in States--
which Dr. Konetzka has testified to--with poor Medicaid rates,
particularly some of the inner city facilities where they have
a large proportion of Medicaid, they are also at higher risk
because they do not have the same resiliency to sort through
this.
I think if we are going to make nursing homes a priority to
avoid this and increase the staffing and make the PPE available
that we need, it is going to have to come through, as Dr.
Konetzka said, sort of a serious look at, what are the
investments we are going to make? And how are we going to make
this a priority going forward? Otherwise, I think in rural
areas, like in your State, you will see closures. It is just
not sustainable.
Senator Thune. On the staffing issue, everybody on the
panel has mentioned those challenges. I have heard that from
facilities in South Dakota for years. Recognizing that Federal
dollars are not unlimited, what solutions should policy-makers
focus on to have the most immediate and positive impact when it
comes to workforce staffing?
Anybody? And I know my time is expiring, so----
Ms. Moten. I think we need to be creative in terms of how
we look at staffing, right? I will take the lead from both
California and Florida, which have programs by which people
graduating from social work, public health nursing, and one
other program are required to participate in programs where
they are going into these facilities.
So again, we should give them that infection control and
universal health precaution education, and start looking at
models with intergenerational aspects. And these are just very
simple things logistically that we can do, especially as it
pertains to our rural communities. Because we are going to
start to see, as Dr. Gifford said, a lot of issues out in those
rural communities where we have seen bed size compared to
census drop drastically.
Senator Thune. Thank you. Thank you, Mr. Chairman.
The Chairman. All right; thank you, Senator Thune.
Senator Hassan?
Senator Hassan. Well, thank you so much, Chairman Wyden and
Ranking Member Crapo, for the hearing. And I really appreciate
all of the witnesses being here today. And I know it has been a
long hearing, so thank you so much to you all for your
testimony and your work.
Dr. Gifford, I want to start with a question for you. The
COVID-19 pandemic has killed more than 174,000 long-term care
residents over the past year. More than 70 percent of all the
COVID-19 deaths in my home State of New Hampshire have occurred
in long-term care settings.
This pandemic exposed clear failures within these
facilities, and in the oversight of these facilities. The
failure to protect this vulnerable population during the
pandemic is a national tragedy.
There are many reasons that this happened, and you have all
discussed a number of them this morning, including the previous
administration's failure to quickly and adequately respond,
leaving nursing home workers and residents more vulnerable. But
nursing homes themselves also need to take a hard look at their
own role, and take responsibility for their failures.
So, Dr. Gifford, do you agree that nursing homes bear some
of the blame for the tragic loss of life we have seen over the
past year? And assuming that you do, what is the most important
thing that went wrong? And what is happening now to correct it
during this crisis and into the future?
Dr. Gifford. You know, I think you have heard from all of
us that this pandemic exacerbated some underlying challenges
that existed in the facilities, particularly around the
staffing issues. But it also, I think, exposed the fact that we
lacked a priority. We have seen in previous hurricanes and
other disasters that the resources go to hospitals and other
areas, and nursing homes are not a priority.
The other thing is, there was just a failure to learn over
time what were the right things to do so we could get rapid
lessons learned out there. So even, as Dr. Konetzka said, doing
all the right things at the time would not have worked, because
they were wrong for this virus.
I think how we learn from each other--we need to do that.
We still do not know what the right frequency of testing is. We
do not know whether opening up for family members to come in is
going to be the right thing to do, and how to do it.
Those are critical things that we need to know going
forward.
Senator Hassan. But, Doctor--I am going to interrupt you,
just because my time is limited. What have you learned that you
can change? What could you do differently? Is it staffing that
you need to really focus on?
Dr. Gifford. Well, I think we have taken a hard look at
that, and I think we agree that we need to have 24-hour R.N.
staffing, knowing R.N.s in a facility are really key to
infection control. I have talked before about the infection
preventions that are necessary. And we think you need to
stockpile PPE for a 30-day supply. And we support that.
Senator Hassan. Okay; so thank you.
I want to move to another issue, because I am sure that you
saw the recent New York Times reporting on the failures of the
Federal rating system for long-term care facilities, and its
reliance on self-reported data.
There appears to be a widespread practice of inflating the
number of reported staff responsible for patient care by
including administrators, some who may not physically work in
the facility. Staff shortages, as all the testimony has
established today, have been a major issue during this
pandemic. And not surprisingly, research suggests that better-
staffed facilities lost fewer patients to COVID-19.
So, Dr. Gifford, given the disturbing record of some homes
manipulating data and the importance of adequate staffing, does
the Federal Government need to increase inspections and end the
reliance on self-reporting?
Dr. Gifford. So, Senator, I think--a couple of things on
the reporting system. There is this perception of self-
reporting. I mean, it is composed of data from the surveyors,
but that is not self-
reported. The staffing data is from payroll data, which is
auditable. And certainly we encourage people to follow the
rules on that issue.
CMS has identified that there are many directors of nursing
or nursing supervisors who have spent some time
administratively and some time providing patient care. Some of
that administrative time is calling families, so that is why
they are counted in that program there.
So I want to make sure you understand what the process is
there.
Senator Hassan. I thank you for that. I am going to move on
to a different issue. But as someone who has worked in a
nursing home, I understand distinctly the difference between
being on the phone to families and being at the bedside.
I want to turn quickly to Ms. Ramos before my time runs
out, because even with vaccine supply increasing, reports
suggest that about half of long-term care facility workers
remain hesitant to take the vaccine.
And I am wondering, Ms. Ramos, how do you see access to
paid sick leave impacting the willingness of front-line workers
to take the vaccine?
Ms. Ramos. Thank you for your question. I think that has a
lot to do with it for workers, not only in health care, but in
general. A lot of people are hesitant to take a vaccine because
they know that there are side effects. And if they take a
vaccine and they get sick, they are afraid that there will be
consequences to pay, like they would use their sick time to pay
them when they are going to need sick time when their family
are sick. Or they will use education time, and when they want
to spend time with their kids, they won't have it because they
used that.
Or like for us health-care workers, we work every other
weekend. So if we take a vaccine on a Friday, and on the
weekend we get sick and we have to call out, we have to make it
up the following weekend when we already have plans to spend it
with our family.
So I think it should be a system where you do not tell the
companies to offer it, but it would be a law, like a mandate,
so it would be better that way than just telling them to offer
this and to offer that, because they will not follow up.
Senator Hassan. Thank you very much. And thank you, Mr.
Chair, for allowing me to go over time.
The Chairman. Thank you, Senator Hassan. And we are moving
towards wrapping up, but there are a couple of areas I want to
get into, because I think we may have missed them.
A question for you, Ms. Bottcher and Dr. Konetzka. My
understanding is that CMS has not required that vaccination
data be made available per facility. Now we are not talking
about every single person's status; we are talking about the
aggregate data on, say, this facility, X percentage have been
vaccinated; this facility, Y percentage have been vaccinated.
That strikes me as important. What do you two think?
Ms. Bottcher. Senator, I think it is incredibly important.
And in fact I spoke to one of our members yesterday, Mark
Ferguson in Lake Charles, LA, and I posed the same question to
him: how important is it that you know about the vaccination
rate at your brother's facility? And he said it was extremely
important. And in particular, although his brother has been
vaccinated, it is important that we look to the future. And if
they need a booster shot, or infection rates start climbing, he
wants to know that information about his brother's facility.
The Chairman. All right.
Dr. Konetzka?
Dr. Konetzka. I agree. I will just add that, yes, we
certainly need that information to be public for consumers.
They have a right to know the vaccination rates in our
facilities they might be considering. It is also essential for
researchers and for public health officials to have that data
to track vaccination rates, to figure out what is working and
what is not working, and whether vaccination is proceeding with
equity.
So I think there is no excuse that those data are not made
available publicly yet.
The Chairman. Good. And the last question I think on my
end, and then I want to kind of sum up where we are: Dr.
Konetzka, do you have any additional recommendations--I had to
be on the floor voting for a bit--with respect to what can be
done to deal with these yawning racial disparities, these
enormous racial disparities? To some extent, they mirror
society, as I touched on earlier, but to some extent they seem
to be even more entrenched, and it is going to take more
careful efforts to root them out. Do you have any final
thoughts with respect to racial disparities in nursing homes?
Dr. Konetzka. Yes, it is an incredibly important issue. So,
as I said, I think we know that racial and ethnic disparities
have been prominent in the pandemic, not only generally but
also in nursing homes. At the same time, long before the
pandemic, people of color tended to be in lower-quality nursing
homes. And those nursing homes have a higher Medicaid census.
Those nursing homes tend to have lower staffing ratios.
I think in the short run--and this goes back to your data
question--in the short run, what we need is data on
vaccinations to make sure that we are reaching their
communities, the communities of color, but also the nursing
homes within them, and that we are getting people vaccinated in
those areas. We need to make sure that strike teams are also
reaching those larger facilities in lower-income neighborhoods.
The long-run problem is harder, again because, as you said,
it sort of reflects residential segregation and the problems
that go along with the wider disparities in the health-care
system. But in the short run, we can certainly target
communities of color to try to reduce those disparities.
The Chairman. All of you have been a terrific panel, and as
you can see, my colleagues kept coming back to these important
points.
Dr. Konetzka, as you know, I think almost 3 hours ago I
asked you about private equity, and the fact that they seemed
to be bringing a ``make money first, and patients somewhere
later will be discussed'' kind of philosophy, and colleagues
kept talking about it all through the hearing.
So we thank you for that. And I could literally go person
by person and mention your contributions. But I want to close--
--
Senator Whitehouse. Mr. Chairman, I am back now--Senator
Whitehouse.
The Chairman. Okay. Would you like to ask anything else? Or
do you want to make----
Senator Whitehouse. If I could drop in one question to Ms.
Ramos----
The Chairman. Good. And then I will close it out. Go ahead.
Senator Whitehouse. Ms. Ramos, when I introduced you, I
described the amazing tragedy that you lived through with all
of the fatalities at the Greenville Nursing Center, including a
colleague, yourself getting the illness, the four of you having
to try to manage--what was it?--two dozen COVID patients.
Could you just put as much of a personal experience before
us of what this all felt like for you and your colleagues
working in the Greenville Nursing Center, and what you have
heard from other colleagues who have been doing the same work
in our nursing homes?
Ms. Ramos. Thank you for your question. So before COVID, we
were going through those issues, and we had been fighting at
the State level to pass the safe staffing, as you know, because
it had been years and years that we had been working under-
staffed, and the quality of care for our residents was getting
worse and worse, and the pandemic made it even worse.
So in those times, I remember when our first unit got
COVID. We were not allowed to visit our patients. We normally
would take up a shift in those units because we had known them
forever.
Senator Whitehouse. You know them well. I mean, they are
people in your life, right, the patients?
Ms. Ramos. Yes. They are like a family to us. So a lot of--
we kept texting our co-workers in that unit and encouraging
them, and they kept telling us what was going on in that unit.
If it was a normal day, we know that if somebody was dying, we
could have stayed over after our shift and spent time with
those residents, but because they were a COVID unit, we could
not go there.
And we felt guilty when we heard such-and-such passed away
and we could not be there. Their family could not be there for
them. It was heartbreaking.
And then when it came to my unit, which is the Dementia
unit, it was horrible. Like I said before in my opening
statement, we were working short. There were 26 residents who
were very ill, and the other CNA and I and a nurse and a
housekeeper.
The nurse was overwhelmed. She have a lot to do. And she
could not help us, and we could not help her. So we had to do
the best we could. I remember my resident telling me she was
scared. And I kept telling her, ``It's okay.'' And then she was
like, ``No, can you stay with me?'' And I couldn't stay with
her to hold her hand. And I held her hand for a few seconds,
and then I told her I had to go because somebody else needed
me.
And she looked at me with a sad face, and she didn't want
me to leave. And her family couldn't come in to hold her hand.
And then I remember, that day a resident passed away. And then
the funeral home couldn't come in to get the resident. They
normally, on a regular day, before the pandemic, they came in
and picked up the resident and we walked away once we put the
resident in the bag, and we walked out the resident.
So our job was a resident passing away, and we had to--it
was the hardest part--we had to put the resident in a bag, in a
body bag. And those other residents, they are like a family,
and we love them. So imagine if it's your own family who passed
away at home and you have to put them in a body bag. And then
we had to bring them outside.
So it was horrifying. We worked short all the time, and I
am glad that we have a union that has our back. We made
complaints, and the union did what they had to do. And then
finally we got agency staff who came in to help us.
But the thing is, management were not there to help us.
Like when we need help, we ask for help from management. If I
am a CNA and a nurse, and another CNA is feeding a resident
because that resident can't feed herself, then we call for help
to come feed. They don't come to the floor. Another resident
asked me, ``I need to go to the bathroom.''
So I have to make a choice right there and then. I have to
leave that resident with the tray in front of them--that
resident can't feed themselves--and take the other resident to
the bathroom. Because with short staff, we don't have another
staffer who would take over. And those are the choices that we
had to make day to day before the pandemic, and with the
pandemic, things got worse.
It is a sad situation, but I don't think it should just be
a safe level that we're fighting for. Our union is fighting
across the country to change the staffing of nursing homes. I
think you guys have the power and that you can change it and
have oversight in these nursing homes, and make it better for
the quality of care for our residents and for our staff. Our
staff are not leaving the nursing homes because they don't want
to work in a nursing home; that is not the reason why they are
leaving the nursing homes. They are leaving the nursing homes
because the workload is a lot for the nurses and the CNAs. And
they go work at the hospital where they will get less patients,
and they pay them more than a nursing home.
They don't want to leave their residents, but they have to
look at it with their health too at risk, and they don't want
to go home exhausted after a long day at work, you know?
Senator Whitehouse. Well, thank you so much, Ms. Ramos.
People call you and your colleagues heroes for a reason. You
are heroes of the heart, and I thank you for being here.
The Chairman. Ms. Ramos, you have another Senator who, I am
sure, is very interested in your view as well, and we want to
hear from her: Catherine Cortez Masto.
Senator Cortez Masto. Thank you, Mr. Chairman and Ranking
Member. This has been an incredible conversation.
Ms. Ramos, I am going to follow up because I truly agree
with Senator Whitehouse. There are so many heroes on the front
line right now, including you and so many at the SEIU and the
work that you are doing.
My challenge has been--and I am hoping you can help with
this--and I think the conversation you were having was, how do
we attract more staff at the long-term care facilities?
Can you talk a little bit about the benefits and other
things? What should we be doing? How do we attract them to make
sure that we are not only getting them into the facilities
because they are under-staffed, but taking care of them as
well?
Ms. Ramos. Thank you for your question. The way that we
attract them is to put the starting rate higher than it is
right now. Because nursing homes' starting rate is very low for
CNAs, and they can go to hospitals and make more, or they can
work for agencies that are making double what we make.
So those are the challenges. And also, the staffing. They
need to change the staffing in the nursing homes. Because if
someone starts working in a nursing home and they end up having
12, 13 patients who are total care--they cannot do anything for
themselves--within 3 months, they leave. And they get the
experience that they need. They leave the nursing home, and
they go to work somewhere else because, you know, they're like,
``I can't do this job, because it's a lot and they don't pay
enough.''
So those are the main challenges that we face in the
nursing homes. And I am grateful that I have a union that
fights for better wages and better staffing in nursing homes,
but when you're fighting for it State by State--we want this
fight to go across the country.
Senator Cortez Masto. Thank you. Thank you so much, and for
your advocacy. It is so important.
Let me jump to, I believe it's Dr. Konetzka. I know there
has been talk about private equity now being involved with
long-term care, but can you opine on what sort of guard rails
Congress should consider to ensure that additional resources
that flow to long-term care facilities are invested in patient
care and staff?
Dr. Konetzka. Yes, it is an important question. And I think
the first step is transparency. Right now, we just do not know
where the money is flowing. So you know, we need to make
reporting of those arrangements mandatory and assess where we
are and whether current reimbursements are enough, or what else
we need to invest into the system.
And then, I think the next step would be to consider some
more oversight or regulation of these arrangements. When there
is so much public money involved, I think some accountability
is warranted. And we should be able to make sure, when we put
Medicare and Medicaid money into nursing homes, that at least a
certain proportion of it goes to patient care.
Senator Cortez Masto. Thank you.
Again, this conversation today has been so helpful, I think
to all of us. We so appreciate having this hearing today, Mr.
Chairman, and I yield back to you.
The Chairman. I thank my colleague. And I know of her
advocacy for seniors.
Here is my take on where things are. This has really been
the area I have focused on in my time in public service. I was
director of the Gray Panthers, ran the legal aid office for the
elderly, and I have long known that, from sea to shining sea,
there are persons who care deeply about the well-being of those
patients in nursing homes.
And, Ms. Ramos, I can tell you--because I have visited with
a couple of my colleagues when we were voting--you have left
our members with a very clear call to action. You spelled it
out: here are the problems, and the buck is not at the State
level or the local level, or anywhere else; it is in the U.S.
Congress. And the Senate Finance Committee has jurisdiction
over this area.
I so appreciate what you have done. I appreciate all of
you, and I think if I were to sum it up, despite all of the
caring, good people who work in a number of nursing homes in
America, we have still seen in the last year what I describe as
a collision of mismanagement at every level. And Ms. Ramos
started it off 3 hours ago when she talked about under-staffing
and infection. And then she talked about the problems with PPE,
not even being able to get basic protective equipment. And then
she described, ``Hey, by the way, we are also kind of in the
dark. We have had difficulty getting information.''
So I have had a number of opportunities over the years to
hear about what needs to be done in terms of long-term care,
and I think this has been a stellar panel. You have spelled it
out.
Ms. Ramos has made it really clear. She is going to hold
the Congress of the United States accountable. And that is
exactly what we need. So I want you to know that I guess I am
calling an end to the hearing for today, but let me tell you
something. This hearing and the issues that we are going to be
focused on, because of what you have said today and your call
to action and accountability, is not something to be swept
away. This is to be continued.
I thank you all. Terrific hearing, and I look forward to
staying in touch.
Oh, I have one other matter. I would like to thank Ranking
Member Crapo and all committee members for their participation.
We thank our witnesses, of course, and for the information of
all members, questions for the record should be submitted by 5
p.m. on Wednesday, March 24th. And with that, the hearing is
adjourned.
Ms. Ramos. Thank you.
[Whereupon, at 12:55 p.m., the hearing was concluded.]
A P P E N D I X
Additional Material Submitted for the Record
----------
Prepared Statement of Denise Bottcher,
State Director, AARP Louisiana
Chairman Wyden, Ranking Member Crapo, and members of the committee,
thank you for inviting AARP to testify today. My name is Denise
Bottcher and I am the State director for AARP Louisiana. On behalf of
our 38 million members, including over 425,000 in Louisiana, and all
older Americans nationwide, AARP appreciates the opportunity to provide
testimony at today's hearing. The situation in our nation's nursing
homes and other long-term care facilities has been alarming since the
beginning of the pandemic. Since then, AARP has consistently advocated
for the health, safety and well-being of residents and staff.
These facilities have been ground zero in the fight against the
coronavirus, representing a shockingly high share of COVID-19 deaths.
Over 175,000 long-term care facility residents and staff have died--
including almost 3,000 in Louisiana--due to COVID-19, representing
about 35 percent of the deaths nationwide and over 30 percent of deaths
in Louisiana, even though nursing home residents comprise less than one
percent of the U.S. population.
These horrifying numbers are a tragedy and national disgrace. AARP
has heard from thousands of people across the country whose loved
ones--their mothers, fathers, grandparents, aunts, uncles, and dear
friends--lost their lives, alone, in nursing homes. We recognize that
even before the pandemic, many long-term care facilities struggled with
basic infection control and adequate staffing. And we knew when the
first COVID outbreak occurred at the Kirkwood facility, that the
situation in these facilities was dire.
There were important steps taken, but too often the response was
too slow and inadequate. Much more was and is needed now, and in the
future, to protect residents, staff, their loved ones, and the
surrounding communities from this disease. For the 4-week period ending
February 14, the rates of COVID-19 cases and deaths in nursing homes
were still higher than in late summer, according to AARP's Nursing Home
Dashboard. That is unacceptable. While there may be a sense of relief
with vaccines rolling out and cases and deaths in long-term care
facilities finally declining, there are still too many deaths, and
policy-makers and facilities are not relieved of their responsibility
to protect nursing home residents. The consequences of not addressing
the issues such as infection control, staffing, sufficient personal
protective equipment and testing, oversight, accountability, and not
following guidance is that someone's dad or mom dies. It is not a could
act or should act situation, it is a must act situation. During the
pandemic, AARP has urged action on a five-point plan to slow the spread
and save lives:
1. Ensure facilities have adequate personal protective equipment
for residents, staff, visitors, and others as needed, and prioritize
regular and ongoing testing.
2. Improve transparency on COVID-19 and demographic data,
vaccination rates of residents and staff by facility, and
accountability for taxpayer dollars going to facilities.
3. Ensure access to in-person visitation following Federal and
State guidelines for safety and require continued access to facilitated
virtual visitation for all residents.
4. Ensure quality care for residents through adequate staffing,
oversight, and in-person access to long-term care ombudsman.
5. Reject immunity and hold long-term care facilities accountable
when they fail to provide proper care to residents.
ensure access to personal protective equipment (ppe) and testing
It is critical to provide PPE and ensure its consistent proper use
by all staff caring for individuals in nursing homes, assisted living
facilities, other residential care communities, home and community-
based and other settings. PPE must be available for residents, staff,
visitors, and surveyors.
Centers for Medicare and Medicaid Services (CMS) testing
requirements for nursing home residents and staff have been an
important step. We have strongly supported regular, prioritized testing
of residents and staff as an important mechanism to prevent COVID-19
from entering nursing homes and other long-term care facilities, detect
cases quickly, and stop transmission to additional residents and staff.
Even with vaccines, we know that PPE and regular testing are still
needed to stop the spread of coronavirus and other pathogens. AARP
supports the funding in the American Rescue Plan Act for infection
control and vaccine uptake support provided by quality improvement
organizations to skilled nursing facilities. We also note that one of
the best ways to keep people safe in nursing homes is to send fewer
people to nursing homes who do not need that level of care.
ensure transparency on covid-19, demographic, and
vaccination data, and use of funds by providers
AARP has called for increased transparency of COVID-19 cases and
deaths in long-term care facilities, including demographic data, such
as race and ethnicity. We appreciated the CMS guidance and interim
final rule with comment that took steps towards achieving greater
transparency on COVID-19 cases and deaths and notification to
residents, their representatives, and families about cases in the
facility, as well as ensuring nursing homes are better prepared to
respond to the public health emergency. While these reporting
requirements are a necessary step, we believe care facilities should
also report publicly daily whether they have confirmed COVID-19 cases
and deaths, and that reporting should include demographic data.
The COVID-19 pandemic has shed light on the stark racial
disparities affecting health outcomes for communities of color across
the country. A recent national study found that nursing homes with a
higher percentage of African American/Black or Hispanic residents had
more than three times as many COVID-19 deaths as those that had a
higher percentage of White residents. While there is a growing body of
data that shows African Americans/Blacks, Hispanics, and American
Indians and Alaska Natives are disproportionately impacted by the
pandemic with higher rates of infection and death, more complete racial
and ethnic data is still needed. Furthermore, there is insufficient
data to fully demonstrate the impact of COVID-19 on Asian American and
Pacific Islander (AAPI) communities, but some disaggregated data show
mortality rates that are disproportionately high in some places.
To disrupt health disparities across the country, including those
occurring within nursing homes and other long-term care facilities, we
need better data. It is important that the Federal Government gather
data and publicly report on COVID-19 cases, deaths, co-morbidities, and
testing rates broken down into multiple demographic categories--while
protecting patient privacy--including race, ethnicity, age,
socioeconomic status, sexual orientation, gender identity, spoken/
written language and disability. Data should also include venues such
as hospitals, nursing homes, assisted living facilities, residential
homes, and other locations. The information, disaggregated for all
groups, should also be contrasted with 2019 numbers to truly understand
the impact of COVID-19 on all communities. Collection, analysis, and
regular public reporting of the detailed disaggregated information will
help us effectively understand and respond to the crisis in a timely
and focused way so that we can minimize the spread of the virus and
improve health outcomes now and into the future. Indeed, given what we
have learned in this crisis, improved data collection and reporting
needs to be an ongoing practice for all long-term care facilities.
In addition, we believe vaccination data also needs to be broken
down by age, race, and ethnicity for States, the Federal Government,
and consumers to fully understand where the gaps are in vaccination
administration. It is of utmost importance that this information be
updated as quickly as possible, even daily. Furthermore, separate
information about the number and percentage of residents and staff who
have been vaccinated should be available by facility and State. While
vaccines have given us all great hope of returning to normalcy,
vaccines only work when they have been administered. We are deeply
concerned about reports that there is a lack of vaccine confidence
among long-term care staff. Policy-makers at the Federal and State
level need to urgently focus their attention on this critical
population to communicate clearly and credibly with these staff about
the vaccines. Moreover, while the Long-Term Care Partnership with CVS
and Walgreens was able to provide vaccines to residents and staff who
wanted them, it is critical that vaccines remain available to new
residents and staff, or those who initially opted out. We urge the
Federal Government to work with States and long-term care facilities to
ensure they can access and administer vaccines as needed.
We also need greater transparency on how the billions of dollars in
taxpayer money from the Provider Relief Fund that have gone to
facilities have been spent. Furthermore, if nursing homes or other
long-term care facilities receive any additional dollars from the
Provider Relief Fund or similar funds, AARP strongly urges that the
administration and Congress ensure that such funding is used
exclusively for the health, safety, and well-being of residents and
staff, such as for PPE, testing, staffing, virtual visitation,
infection control and other items that directly relate to resident care
and well-being, prevention, and treatment. Facilities should be
accountable for their use of taxpayer dollars, and funds should
directly benefit residents.
ensure safe in-person visitation and require facilities
to provide and facilitate virtual visitation
For many Americans living in nursing homes and other facilities,
their friends and family provide not only a source of comfort, but also
an important safety check. In-person visits, with some exceptions, have
largely been halted over most of the past year.
We were pleased that CMS provided updated nursing home visitation
guidance on March 10 that allows easier in-person visitation at nursing
homes, while continuing to emphasize infection prevention and control
practices for facilities, visitors, and others. This is very welcome
news for nursing home residents and families.
In the year since the pandemic began, we have heard heartbreaking
stories about the challenges families have had trying to see their
relatives and the many important moments they missed. As we enter a new
phase of this pandemic with the ongoing rollout of vaccines and growing
knowledge about public health needs--including the safety, mental
health, and social well-being of nursing home residents--it is vital
that these vulnerable seniors can safely visit with their loved ones.
Residents must be able to exercise their rights to visitation, and
facilities should be held accountable for facilitating in-person
visitation. AARP wrote to CMS on February 23 urging the agency to
update its guidance, criteria, and support for safe in-person
visitation.
While not a replacement for in-person visits, virtual visits can be
an important lifeline for families, friends, and residents. We have
urged Congress to require residential care facilities to make available
and facilitate virtual visitation via videoconference or other
technologies for residents and their loved ones. We also urge Congress
to provide funding to support virtual visitation. AARP supports the
bipartisan Advancing Connectivity during the Coronavirus to Ensure
Support for Seniors Act (S. 57/H.R. 596), that would provide such
funding, specifically grants to nursing homes to support virtual
visits.
ensure adequate staff, oversight, and access for long-term care
ombudsmen
We are deeply concerned about staffing shortages at residential
care facilities. AARP's Nursing Home Dashboard has consistently found
over 25 percent of nursing homes nationally reporting a shortage of
direct care workers since June 2020. It is essential that, at a
minimum, staff/resident levels be maintained despite a potential
reduction in workforce due to COVID-19 related circumstances. Many
facilities had inadequate staff prior to the pandemic, and it is
essential that staff be adequate to meet residents' many COVID- and
non-COVID-related care needs, including infection control. Across the
country, we have seen that higher staffing levels are associated with
fewer deaths and COVID-19 cases in nursing homes. In addition, research
shows that nursing homes with a registered nurse on staff help improve
the quality of care. AARP supports funding in the American Rescue Plan
Act for State strike teams in nursing homes with COVID-19 cases. AARP
further urges Congress to take action to ensure that staffing levels in
long-term care facilities are adequate, such as through pay and other
compensation, paid leave, recruitment, training, and retention.
It also remains important for residents to have in-person access to
long-term care ombudsmen, who play an important role in advocating for
residents and their families.
More broadly, oversight from CMS and State survey agencies,
including regular surveys, is vital now more than ever to ensure
facilities are providing quality care and that resident health, safety,
well-being, quality of life, and rights are protected. Strong
enforcement action should be taken, when needed, to protect residents
and ensure their rights. AARP also supports funding included in the
American Rescue Plan Act for Elder Justice Act programs.
reject immunity for nursing homes and other long-term
care facilities and hold them accountable
The pandemic has put residents' health, safety, and quality of care
at unprecedented risk, as reflected by the horrific death tolls. We
know that staff in many long-term care facilities are doing heroic
work, putting their own health on the line to care for people in
nursing homes. But sadly, AARP has heard from thousands of families
across the country whose loved ones were not treated with the
compassion or dignity that every American deserves. AARP strongly urges
Congress to protect the safety of residents, including by maintaining
the rights of residents and their families to seek legal redress to
hold facilities accountable when residents are harmed, neglected, or
abused.
support individuals to remain in their homes and communities
While we work to reform our Nation's long-term care facilities, we
need to support the ability of people to remain in their homes and
communities. Not only will this help people to live where they want to
be, but also help to alleviate some of the challenges we are facing in
our Nation's nursing homes. Furthermore, on average, for every one
person residing in a nursing home, Medicaid can fund three individuals
receiving community-based long-term care.
Congress must also look longer-term to give older adults and people
with disabilities more options to live in their homes and communities,
including more options to receive care at home, and more support for
family caregivers who help make it possible. A family caregiver tax
credit, as in the bipartisan, bicameral Credit for Caring Act, would
help provide some financial relief to eligible family caregivers.
The pandemic has also highlighted the need to transform nursing
homes, including by supporting or incentivizing small house nursing
homes, such as Green Houses with private rooms and an empowered staff,
making available private rooms, and creating a direct care ratio or
medical loss ratio for nursing homes to ensure that public funds going
to these facilities are used for resident care.
Families across the country are looking to Congress and the
administration for swift action to protect the health and safety of
their loved ones living in long-term care facilities now and in the
future. We cannot wait any longer. Thank you again for your attention
to this urgent challenge.
______
Questions Submitted for the Record to Denise Bottcher
Questions Submitted by Hon. Ron Wyden
Question. The Centers for Medicare and Medicaid Services (CMS)
issued an interim final rule last year that required nursing homes to
report COVID-19 data to the Centers for Disease Control and Prevention
on a weekly basis beginning May 17, 2020. These data included COVID-19
infections, COVID-19 deaths, and the availability of key equipment and
workers at individual nursing homes. The data have proved to be helpful
for the public, policy-makers, and industry stakeholders to track the
pandemic, and related issues, in these care settings. However, to date,
CMS has not required nursing homes to provide such data prior to May 8,
2020, despite calls from Senate Democrats to do so. In September 2020,
the Government Accountability Office (GAO) noted that ``by not
requiring nursing homes to submit data from the first 4 months of 2020,
HHS is limiting the usefulness of the data in helping to understand the
effects of COVID-19 in nursing homes.'' GAO went on to recommend that
``HHS, in consultation with CMS and CDC, develop a strategy to capture
more complete data on COVID-19 cases and deaths in nursing homes
retroactively back to January 1, 2020.''
Do you support GAO's recommendation? Why or why not? Please briefly
explain.
Answer. Yes, AARP has supported the collection of data on COVID-19
cases and deaths in nursing homes retroactively prior to May 8th.
Without this data, there is an incomplete State and national picture of
COVID-19's impact on nursing home residents and staff. Given that
nursing homes were not required to report COVID-19 cases and deaths to
the Centers for Medicare and Medicaid Services (CMS) until May, the
numbers of COVID-19 cases and deaths reported by nursing homes are a
significant undercount before June 2020 in this data source.
Transparency is important and can help provide learnings to address
issues and help make sure they do not happen again in the future.
Question. A recent paper published by the National Bureau of
Economic Research noted that people who receive treatment in nursing
homes owned by private equity firms have worse health outcomes than
those living in facilities under other ownership structurers. This
paper adds evidence to reports of worse outcomes associated with
private equity's investment in the nursing home industry. Nursing homes
have also become popular investments for real estate investment trusts
(REITs), which often lease back properties to private equity firms or
other related parties. The involvement of private equity in the nursing
home industry has been of interest to the Finance Committee for more
than a decade, and was a topic of interest for members during this
hearing.
How would additional ownership transparency benefit families and
patients as they consider nursing homes for themselves or their loved
ones?
Answer. If consumers and their families have information about how
a particular nursing home's ownership impacts or may impact the quality
of care or quality of life residents receive in that nursing home, it
could help them make more informed choices about whether that nursing
home is appropriate for them and will meet their needs. It is important
that information for consumers and their families is
consumer-friendly and easily understandable.
Question. Section 6101 of the ACA sought to increase transparency
of nursing home ownership structurers. To date, CMS has not fully
implemented or enforced this section of the ACA, although the agency
does have existing reporting mechanisms for nursing home ownership that
provide a certain amount of information to the public. As the committee
considers the changing ownership landscape in the nursing home
industry, would implementing section 6101 provide sufficient
transparency? Would you suggest additional measures the committee
should consider?
Answer. Fully implementing current law is an important step. We
suggest that the committee seek technical assistance from the Centers
for Medicare and Medicaid Services and consult with researchers and
others who have more closely examined private equity ownership to see
what gaps may remain, and what additional measures may be needed to
capture relevant data and information that may be important to families
and the general public.
Question. COVID-19's toll on nursing homes has not been limited to
viral infections. Residents have suffered mentally and physically, and
had less access to family members and patient advocates. On March 10,
2021, the Centers for Medicare and Medicaid Services issued new
guidance that allows for residents to more easily receive visitors. On
the same day, the Centers for Disease Control and Prevention issued
Updated Healthcare Infection Prevention and Control Recommendations in
Response to COVID-19, which stated ``quarantine is no longer
recommended for residents who are being admitted to a post-acute care
facility if they are fully vaccinated and have not had prolonged close
contact with someone with SARS-coV-2 infection in the prior 14 days.''
The committee has received written testimony for this hearing from
medical experts raising concerns that the new guidance may be overly
permissive, and could put nursing home residents in danger,
particularly if COVID-19 variants breakthrough vaccine protections. On
the other hand, some advocates have called for more permissive
visitation guidelines.
Do you view the guidance as properly balanced? Do you think there
needs to be adjustments to protect the safety of residents and workers?
Answer. Throughout the pandemic, scientists across the globe have
worked hard to better understand this virus and the disease it causes.
We appreciate that as the science has progressed, the Centers for
Medicare and Medicaid Services (CMS) and the Centers for Disease
Control and Prevention (CDC) have adapted their ongoing guidance
related to nursing homes. Informed learnings about public health
needs--including the physical safety, mental health, and social well-
being of nursing home residents--and ongoing vigilance to ensure these
things is vital, especially given the impact of COVID-19 on nursing
home residents and staff. Continued learnings, assessment, and
information based on science, should inform guidance from CMS and CDC,
which is important on these issues and will continue to be going
forward.
Question. Preliminary research conducted by Columbia University
researchers suggests that the Pfizer and Moderna vaccines were up to 12
times less effective at neutralizing the B.1.351 COVID-19 variant
(``South African variant'') than earlier strains of the coronavirus.\1\
The researchers also found that convalescent plasma was 9 times less
effective against the South African variants, leading them to write
``[t]aken together, the overall findings are worrisome, particularly in
light of recent reports that both Novavax and Johnson & Johnson
vaccines showed a substantial drop in efficacy in South Africa.''\2\
The researchers went on to write, ``mutationally, this virus is
traveling in a direction that could ultimately lead to escape from our
current therapeutic and prophylactic interventions directed to the
viral spike. If the rampant spread of the virus continues and more
critical mutations accumulate, then we may be condemned to chasing
after the evolving SARS-CoV-2 continually, as we have long done for
influenza virus.''\3\ The Centers for Disease Control and Prevention
(CDC) has previously found suspected cases of reinfection among nursing
home residents who previously tested positive for COVID-19.\4\
Similarly, a paper published earlier this year in The Lancet suggested
that a resurgence in COVID-19 cases in the Brazilian city of Manaus may
have been due to a new variant (known as P1 or ``Brazilian variant'')
``may evade immunity generated in response to previous infections.''\5\
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\1\ https://www.nature.com/articles/s41586-021-03398-
2_reference.pdf?utm_medium=affiliate&
utm_source=commission_junction&utm_campaign=3_nsn6445_deeplink_PID100024
933&utm_
content=deeplink.
\2\ https://www.nature.com/articles/s41586-021-03398-
2_reference.pdf?utm_medium=affiliate&
utm_source=commission_junction&utm_campaign=3_nsn6445_deeplink_PID100024
933&utm_
content=deeplink.
\3\ https://www.nature.com/articles/s41586-021-03398-
2_reference.pdf?utm_medium=affiliate&
utm_source=commission_junction&utm_campaign=3_nsn6445_deeplink_PID100024
933&utm_
content=deeplink.
\4\ https://www.cdc.gov/mmwr/volumes/70/wr/mm7008a3.htm.
\5\ https://www.thelancet.com/article/S0140-6736(21)00183-5/
fulltext.
The South African and Brazilian variants continue to circulate in
the United States.\6\ What is your level of concern about the danger
that these and other COVID-19 variants may pose to nursing homes,
particularly residents who have been most vulnerable to the disease?
---------------------------------------------------------------------------
\6\ https://www.cdc.gov/coronavirus/2019-ncov/transmission/variant-
cases.html.
Answer. While vaccines give us all great hope of returning to
normalcy and we have seen declines in facility cases and deaths, given
the impact of COVID-19 on residents and staff, continued vigilance is
needed to ensure their health, safety, and well-being, including access
to sufficient personal protective equipment (PPE) and testing. More
than 182,000 residents and staff of nursing homes and other long-term
care facilities have died due to COVID-19, representing about one-third
of all COVID-19 deaths nationwide to date. These horrifying numbers are
a tragedy and national disgrace, and we must take every precaution to
---------------------------------------------------------------------------
prevent any further outbreaks.
Throughout the pandemic, scientists across the globe have worked
hard to better understand this virus and the disease it causes. We
appreciate that as the science has progressed, the Centers for Medicare
and Medicaid Services (CMS) and the Centers for Disease Control and
Prevention (CDC) have adapted their ongoing guidance related to nursing
homes. Continued learnings and guidance from CMS and CDC will be
important going forward.
Question. Is additional surveillance necessary to detect the spread
of viral variants? What types of surveillance, if any, should be
implemented in regards to the nursing home industry specifically?
Answer. Ongoing and improved public health surveillance related to
COVID-19 and variants is important to understand how they are impacting
individuals and the population overall. The Centers for Disease Control
and Prevention (CDC) and Centers for Medicare and Medicaid Services
(CMS) should work together to determine what types of additional
surveillance, if any, should be implemented in relation to the nursing
home industry. AARP has urged greater transparency around COVID-19 and
nursing homes, including on COVID-19 cases and deaths, demographic
data, and vaccination rates of residents and staff by facility. If
there is additional surveillance, timely information should be shared
with the public, residents, families, and staff.
Question. In the event that additional vaccinations and/or booster
shots are needed to protect against variants, do you have a view on
what would be the best model to accomplish such a rollout, and what
would be a reasonable amount of time?
Answer. We would encourage looking at the successes, experiences,
and lessons learned from the Pharmacy Partnership for Long-Term Care
Program and other State experiences with vaccinations in long-term care
facilities. Using a model informed by those experiences, and perhaps
similar to the Partnership, would be a good place to start. Timing
should be informed by that previous experience and the protocol for
additional vaccinations and/or booster shots, but once such
vaccinations or booster shots are available they should be administered
as effectively, efficiently, and quickly as possible. Given the risk to
older populations, nursing home and other long-term care facility
residents and older Americans should be prioritized. There should also
be a clear plan from the beginning to ensure ongoing access to
additional vaccinations and/or booster shots for residents and staff
after the initial rollout.
Question. What lessons can be drawn from the experience of the CVS-
Walgreen Long-Term Care Partnership in regards to additional
vaccination campaigns?
Answer. It is important to learn from what worked well in terms of
the successful vaccination of residents and staff, as well as other
lessons including the importance of educating residents, staff, and
families about the vaccine and building vaccine confidence, especially
among staff; having multiple ways to get consent for vaccination;
ensuring sufficient vaccine supply and addressing initial distribution
problems; improved allocation of the number of needed doses; and having
a clear plan from the beginning to ensure ongoing access to additional
vaccinations and/or booster shots for residents and staff after the
initial rollout.
______
Question Submitted by Hon. Patrick J. Toomey
Question. Prior to the COVID-19 pandemic, I worked alongside my
Pennsylvania colleague Senator Casey to address the quality of care for
nursing homes residents. We were successful in pressing the Centers for
Medicare and Medicaid Services (CMS) to publicize both participants and
candidates affiliated with the Special Focus Facility (SFF) program,
which provides more frequent oversight of facilities that consistently
fail to meet Federal safety and care requirements.
Specific to this issue, Senator Casey and I reintroduced the
Nursing Home Reform Modernization Act (S. 782) on March 16, 2021, which
would expand the SFF program to ensure that all facilities nominated as
candidates for the program receive additional oversight. Our
legislation would also increase educational resources for
underperforming facilities and create an independent advisory panel to
inform CMS on how best to rank nursing home performance.
AARP has been instrumental in crafting our legislation and has
endorsed the bill. Can you discuss the impact this legislation will
have on nursing home residents?
Answer. AARP appreciates the bipartisan work that you and Senator
Casey put into the Nursing Home Reform Modernization Act. Importantly,
as you note, your bill would expand the number of nursing homes in the
Special Focus Facility (SFF) Program to identify and increase
transparency around those facilities with a history of serious quality
issues and ensure they receive more frequent inspections. Inspections
can help identify important quality of care issues or problems that
must be addressed by a facility to ensure resident health and safety.
The legislation also includes vital consumer protections to help
ensure appropriate oversight and accountability for nursing homes and
requires consumer participation in an Advisory Council examining
processes for ranking nursing homes prior to the establishment of such
a ranking system. It is important for consumers to have representation
on this Advisory Council, so that their voices and experiences help
inform the Council's work.
______
Question Submitted by Hon. John Barrasso
Question. A top concern of Wyoming nursing facilities is making
sure there are enough staff to care for residents.
Many Wyoming nursing homes provide professional development and
other educational opportunities to attract and maintain their staff.
Can you discuss solutions related to workforce development you
believe will improve the ability of nursing facilities to attract and
maintain direct care staff?
Answer. COVID-19 exacerbated existing direct care staff shortages
that pre-dated the pandemic. It is essential that, at a minimum, staff/
resident levels be maintained despite a potential reduction in
workforce due to COVID-19 related circumstances. Across the country, we
have seen that higher staffing levels are associated with fewer deaths
and COVID-19 cases in nursing homes. In addition, research shows that
nursing homes with a registered nurse on staff help improve the quality
of care. AARP supported funding in recently enacted legislation for
State strike teams in nursing homes with COVID-19 cases. This would
help provide additional support to facilities when they need it most.
AARP has further urged Congress to act to ensure that staffing levels
in long-term care facilities are adequate, such as through pay and
other compensation, paid leave, recruitment, training, and retention.
______
Questions Submitted by Hon. Todd Young
Question. As outlined in many of your testimonies, the visiting
restrictions and isolation necessitated by the COVID-19 pandemic took a
heavy toll on the emotional and mental health of many nursing home
residents separated from their family members and other loved ones.
Fortunately, with increased vaccination and declining COVID-19 deaths,
many of these restrictions have been lifted.
While we hope that restrictions of this scale will not be necessary
again, it is worth examining ways to alleviate the negative emotional
and mental health effects that isolation may have on nursing home
residents. The use of technology, for one, has allowed residents to
interact virtually with family and other loved ones from whom they are
otherwise separated. Expanded use of telehealth has also helped
residents access routine health-care services while limiting spread of
the coronavirus.
What are some lessons learned from the public health emergency in
terms of the integration of technology in nursing homes--both in
helping residents visit virtually with loved ones and in accessing
health-care services?
Answer. The COVID-19 pandemic increased the use of technology in
nursing homes for virtual visits with loved ones and accessing health-
care services through telehealth. While not a replacement for in-person
visits, virtual visits can be an important lifeline for families,
friends, and residents both as a source of comfort and an important
safety check. Access to these visits is important. Among the lessons
learned are the importance of access to the necessary technology,
including videoconference or similar technology to enable residents to
see their family and friends, and funding for it; designated staff to
facilitate virtual visits with residents (including assisting with the
use of the technology and scheduling visits); regular cleaning and
disinfecting of devices; and the availability of broadband access to
use the technology. It is also important for facilities to communicate
clearly with residents and families about how to access virtual visits.
The use of telehealth in nursing homes during the pandemic has
helped ensure more efficient and effective access to health care.
Telehealth is an effective way to deliver care while preserving
physical distancing and minimizing risk of COVID-19 exposure. In
addition, telehealth may enable the participation of family caregivers
in the visit with the consent of the resident. This could help with
care coordination, care continuity, a smooth discharge from a skilled
nursing facility, and care at home post-discharge. AARP has supported
greater access to telehealth for Medicare beneficiaries, and CMS has
made many temporary changes to increase telehealth access during the
public health emergency. Data from these temporary administrative
policy changes should be examined before they are made permanent by
congressional action. Specifically, individual telehealth services
should be reviewed for their impact on quality of care and disparities.
We would also encourage policy-makers to fully update and enforce the
Health Insurance Portability and Accountability Act (HIPAA)--to reflect
changes in technology and utilization--alongside making permanent
policy changes. We also note that the use of telehealth is a tool meant
to supplement, not replace, necessary in-person care.
Question. How do you anticipate this type of technology continuing
to be used beyond the pandemic?
Answer. Beyond the pandemic, virtual visits can enable residents to
visit with loved ones who may be unable to visit in person for a
variety of reasons, including but not limited to distance or illness.
Virtual visits can also be helpful and important if a resident is sick
or not feeling well, to enable a larger group of individuals to visit
with a resident, and to enable family and friends to check in on their
loved ones. Technology can also help enable the participation of family
caregivers--with the consent of the resident--to assist with care
coordination, care continuity, a smooth discharge from a skilled
nursing facility, and care at home post-discharge.
______
Submitted by Hon. Sherrod Brown, a U.S. Senator From Ohio
NBER WORKING PAPER SERIES
DOES PRIVATE EQUITY INVESTMENT IN HEALTHCARE BENEFIT PATIENTS? EVIDENCE
FROM NURSING HOMES
Atul Gupta
Sabrina T. Howell
Constantine Yannelis
Abhinav Gupta
Working Paper 28474
http://www.nber.org/papers/w28474
NATIONAL BUREAU OF ECONOMIC RESEARCH
1050 Massachusetts Avenue
Cambridge, MA 02138
February 2021
We are grateful to Abby Alpert, Pierre Azoulay, Zack Cooper, Liran
Einav, Matthew Grennan, Arpit Gupta, Jarrad Harford, Steve Kaplan,
Holger Mueller, Aviv Nevo, Adam Sacarny, Albert Sheen, Arthur Robin
Williams, and participants at the NBER Aging Summer Institute, American
Economics Association, UBC Winter Finance Conference, Whistler Junior
Health Economics Summit, Virtual Corporate Finance Seminar, ESSEC,
Norwegian School of Economics, Oklahoma Price, PE Research Consortium
(PERC) Annual Symposium, Tulane, NYU Stern, U Penn Wharton, Yale Health
Policy, Oregon Lundquist, and Johns Hopkins Carey for their comments
and suggestions. Jun Wong, Mei-Lynn Hua, and Sarah Schutz provided
excellent research assistance. We thank Christianna Williams of Abt
Associates for insights into CMS quality measures, Liz Liberman for
industry information, and Mohan Ramanujan at NBER for assistance with
the CMS data. Funding from the Wharton Dean's Research Fund and the
Mack Institute (Gupta), the Kauffman Foundation (Howell), and the Fama
Miller Center at the University of Chicago (Yannelis) is greatly
appreciated. We gratefully acknowledge funding through National
Institute of Aging pilot grant P01AG005842-31. All remaining errors are
our own. The views expressed herein are those of the authors and do not
necessarily reflect the views of the National Bureau of Economic
Research.
NBER working papers are circulated for discussion and comment purposes.
They have not been peer-reviewed or been subject to the review by the
NBER Board of Directors that accompanies official NBER publications.
2021 by Atul Gupta, Sabrina T. Howell, Constantine Yannelis, and
Abhinav Gupta. All rights reserved. Short sections of text, not to
exceed two paragraphs, may be quoted without explicit permission
provided that full credit, including notice, is given to the source.
Does Private Equity Investment in Healthcare Benefit Patients? Evidence
from Nursing Homes Atul Gupta, Sabrina T. Howell, Constantine Yannelis,
and Abhinav Gupta
NBER Working Paper No. 28474
February 2021
JEL No. G3,G32,G34,G38,I1,I18
ABSTRACT
The past two decades have seen a rapid increase in Private Equity (PE)
investment in healthcare, a sector in which intensive government
subsidy and market frictions could lead high-powered for-profit
incentives to be misaligned with the social goal of affordable, quality
care. This paper studies the effects of PE ownership on patient welfare
at nursing homes. With administrative patient-level data, we use a
within-facility differences-in-differences design to address non-random
targeting of facilities. We use an instrumental variables strategy to
control for the selection of patients into nursing homes. Our estimates
show that PE ownership increases the short-term mortality of Medicare
patients by 10%, implying 20,150 lives lost due to PE ownership over
our twelve-year sample period. This is accompanied by declines in other
measures of patient well-being, such as lower mobility, while taxpayer
spending per patient episode increases by 11%. We observe operational
changes that help to explain these effects, including declines in
nursing staff and compliance with standards. Finally, we document a
systematic shift in operating costs post-acquisition toward non-patient
care items such as monitoring fees, interest, and lease payments.
Atul Gupta Constantine Yannelis
Wharton Health Care Management Booth School of Business
3641 Locust Walk, CPC 306 University of Chicago
Philadelphia, PA 19104 5807 S. Woodlawn Avenue
[email protected] Chicago, IL 60637
and NBER
Sabrina T. Howell [email protected]
u
NYU Stern School of Business
KMC 9-93 Abhinav Gupta
44 West 4th Street New York University
New York, NY 10012 [email protected]
and NBER
[email protected]
1 Introduction
The U.S. spends more than other developed countries on healthcare, yet
has worse health outcomes (Garber and Skinner, 2008). In light of
evidence from other sectors, private equity (PE) ownership of
healthcare providers could improve productivity (Kaplan, 1989; Davis et
al., 2014; Bloom et al., 2015b; Bernstein and Sheen, 2016). PE
ownership can affect firm performance because it confers distinct
incentives to quickly and substantially increase firm value.\1\
However, PE's success in other sectors may not be relevant to
healthcare, which suffers from unique market frictions. For example,
patients cannot accurately assess provider quality, they typically do
not pay for services directly, and a web of government agencies act as
both payers and regulators (Cutler, 2011; Skinner, 2011). These
features weaken the natural ability of a market to align firm
incentives with consumer welfare and could mean that high-powered
incentives to maximize profits have detrimental implications for
consumer welfare (Hansmann, 1980; Hart et al., 1997; Chandra et al.,
2016).
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\1\ See Section 2.2 for an explanation of PE and its incentive
structure.
Policymakers appear increasingly concerned about this possibility
given the rapid growth of PE in healthcare. For example, in 2019 U.S.
Senators asked about ``the role of PE firms in the nursing home care
industry, and the extent to which these firms' emphasis on profits and
short-term return is responsible for declines in quality of care,''
while a member of the British Parliament argued that PE-owned nursing
homes in the UK pursue ``profiteering, cost and corner cutting, all the
while their owners are loading them up on debt with high interest rates
and expecting the taxpayer to pay when it fails'' (Brown et al., 2019;
Hodgson, 2020).\2\ Meanwhile, voices from the private sector often
paint a different picture; for example, a 2019 report from consulting
firm EY concluded that ``Not only is PE perceived to have a beneficial
overall impact on health care businesses, it is also considered to
positively influence the focus on quality and clinical services''
(Saenz, 2019).
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\2\ Policymaker concern has focused not only on nursing home
quality (Doggett et al., 2020), but also surprise medical bills (Cooper
et al., 2020) and predatory acquisitions of physician practices (King,
2020), among other areas. Also see Flood (2019) and Lewis (2019).
This debate has come to the fore in part because of rising PE
activity in U.S. healthcare over the last two decades, with total
investment increasing from less than $5 billion in 2000 to more than
$100 billion in 2018 (Appelbaum and Batt, 2020). PE-owned firms provide
the staffing for more than one-third of emergency rooms, own large
hospital and nursing home chains, and are rapidly expanding ownership
of physician practices.\3\ Thus far, evidence to inform the animated
policy discussion is limited and inconclusive.
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\3\ See Bruch et al. (2020); Brown et al. (2020); Casalino (2020).
We focus on nursing homes in the U.S., which represent a large
sector with spending at $166 billion in 2017 projected to grow to $240
billion by 2025 (Martin et al., 2018). Nursing homes offer an
attractive setting in which to examine the impact of PE in healthcare.
First, they have historically had a high rate of for-profit ownership
(about 70%), allowing us to study the effects of PE ownership relative
to for-profit ownership more generally. Second, PE firms have acquired
both large chains and independent facilities, enabling us to make
progress in isolating the effects of PE ownership from the related
phenomenon of corporatization in medical care (Eliason et al., 2020).
We use patient- and facility-level administrative data from the Centers
for Medicare and Medicaid Services (CMS), which we match to PE deal
data. The data include 18,485 unique nursing homes between 2000 and
2017. Of these, 1,674 were acquired by PE firms in 128 unique deals. We
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observe about 7.4 million unique Medicare patients.
We overcome two empirical challenges to estimating causal effects
of PE ownership. The first is non-random selection of acquisition
targets. To address this we include facility fixed effects, which also
eliminate cross-sectional differences in the types of locations where
PE firms tend to buy nursing homes. The second challenge is unobserved
changes in patient composition following PE ownership, perhaps
reflecting new advertising, hospital ties, or patient reactions to
quality. We control for the patient-facility match with a differential
distance instrumental variables (IV) strategy (McClellan et al., 1994;
Grabowski et al., 2013; Card et al., 2019), exploiting patient
preference for a nursing facility close to their home (the median
distance is 4.6 miles). To our knowledge, no national study on PE or on
ownership in healthcare has simultaneously addressed both challenges.
A key measure of patient welfare is short-term survival. We find
that going to a PE-owned nursing home increases the probability of
death during the stay and the following 90 days by 1.7 percentage
points, about 10% of the mean. This estimate implies about 20,150
Medicare lives lost due to PE ownership of nursing homes during our
sample period. We use the observed age and gender distribution of
Medicare decedents to estimate the corresponding implied loss in life-
years--160,000. Using a conventional value of a life- year from the
literature, this estimate implies a mortality cost of about $21 billion
in 2016 dollars. To put this in perspective, this is about twice the
total payments made by Medicare to PE facilities during our sample
period, about $ 9 billion.
The mortality effect is concentrated among older patients,
especially those with relatively low disease burdens. Exploring
treatment effect heterogeneity more formally using Marginal Treatment
Effect (MTE) analysis, we find evidence of reverse selection on
treatment gains, i.e., patients with the lowest unobserved resistance
to going to a PE-owned facility experience the highest increase in
mortality (nearly 4 pp). We estimate an unconditional Average Treatment
Effect (ATE) of about 1.3 pp. Hence, the conclusion that patients are
worse off at PE-owned facilities can be generalized beyond compliers to
the average Medicare patient. However, we also estimate negative MTE
values for patients with the highest unobserved resistance, implying
that a small fraction of patients are better off receiving care at such
facilities.
The effect on mortality is robust to a battery of specification
checks, and does not appear in a placebo analysis testing for pre-
buyout effects. It also remains intact when we restrict our attention
to PE acquisitions of the largest chains, in which chain size remained
constant over the sample period, implying that the effect reflects the
nature of ownership rather than consolidation or corporatization more
broadly. To ensure the effect is not spurious, we study other measures
of patient well-being using the same IV approach. We find that going to
a PE-owned nursing home increases the probability of taking
antipsychotic medications--discouraged in the elderly due to their
association with greater mortality--by 50%. Similarly, patient mobility
declines and pain intensity increases post-acquisition. Finally, the
amount billed per 90-day episode increases by 11%. Taken together,
these results suggest that PE ownership decreases nursing home
productivity, as measured by our proxies for quality output per dollar
spent.
To explore mechanisms for the effect on mortality, we assess
operational changes using facility-level data. Here we are limited to
using a differences-in-differences research design, which has been
standard in the literature on PE effects. We find negative effects on
facility Five Star ratings, which are constructed by CMS to provide
summary information on quality of care. We next consider nurse
availability, which is the most important determinant of quality of
care (Zhang and Grabowski, 2004; Lin, 2014). We find that PE ownership
leads to a 3% decline in hours per patient-day supplied by the
frontline nursing assistants who provide the vast majority of
caregiving hours and perform crucial well-being services such as
mobility assistance, personal interaction, and cleaning to minimize
infection risk and ensure sanitary conditions. Overall staffing
declines by 1.4%.
The loss of front-line staff is most problematic for older but
relatively less sick patients, who drive the mortality result. There
may be less scope to reduce the costs of care for the sicker patients,
as they have explicit medical needs. Elevated antipsychotic use could
also be partly explained as a substitution response to lower nurse
availability (Cawley et al., 2006). We can explain about a third of the
mortality effect using previously published mortality effects of
antipsychotics and lower nurse availability and assuming these factors
are additive (Schneider et al., 2005; Tong, 2011). However, this may be
an understatement if these factors are more harmful when they interact.
Finally, we assess facility finances to shed light on how the
financial strategies particular to the PE industry affect operations. A
puzzle is why nursing homes are attractive targets given their low and
regulated profit margins, often cited at just 1-2%. Using CMS cost
reports, we find that there is no effect of buyouts on net income,
raising the question of how PE firms create value. There are three
types of expenditures that are particularly associated with PE profits
and tax strategies: ``monitoring fees'' charged to portfolio companies,
lease payments after real estate is sold to generate cash flows, and
interest payments reflecting the importance of leverage in the PE
business model (Metrick and Yasuda, 2010; Phalippou et al., 2018). We
find that all three types of expenditures increase after buyouts, with
interest payments rising by over 300%. These results, along with the
decline in nurse availability, suggest a systematic shift in operating
costs away from patient care.
This paper contributes to three strands of the literature. First,
we provide new evidence on the effects of PE ownership on target firm
operations (Boucly et al., 2011), product quality (Lerner et al., 2011;
Fracassi et al., 2020), and value (Gupta and Van Nieuwerburgh, 2019;
Bernstein et al., 2019; Biesinger et al., 2020). We overcome most
limitations of previous studies on PE in healthcare, such as limited
geographies, a short sample period, a lack of patient-level data, or a
small number of deals (Stevenson and Grabowski, 2008; Harrington et
al., 2012; Pradhan et al., 2013, 2014; Cadigan et al., 2015; Huang and
Bowblis, 2019; Gondi and Song, 2019; Casalino, 2020; Gandhi et al.,
2020).
In contrast with much of the existing literature, and likely
reflecting the considerable market frictions in healthcare, our results
suggest that PE owners may breach implicit contracts with stakeholders
to maximize profits (Shleifer and Summers, 1988). Eaton et al. (2019)
come to the same conclusion in their study of PE ownership of colleges.
It is noteworthy that nursing homes operate under much more intense
regulatory scrutiny of their daily operations than do colleges. Hence,
our results raise concerns about the effectiveness of the elaborate
state and federal oversight infrastructure in place to ensure nursing
home quality.
Second, this paper adds to the literature on how provider ownership
interacts with price incentives and regulation in healthcare Duggan
(2000); Grabowski and Hirth (2003); Grabowski et al. (2013); Clemens
and Gottlieb (2014); Adelino et al. (2015); Hill et al. (2019); Curto
et al. (2019).\4\ Some work points to non-pecuniary objectives of
nonprofits as one reason nonprofit providers can outperform for-
profits. Our results appear consistent with this theme, potentially
raising questions about whether antitrust regulators should
prospectively review PE deals in healthcare. While the large deals in
our sample did not soften competition, they may have hurt consumers.\5\
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\4\ There is also a related literature on competition in healthcare
markets: Bloom et al. (2015a), Curto et al. (2021); Grabowski and Hirth
(2003); Dafny et al. (2012); Cooper et al. (2018); Pelech (2018); Ho
and Lee (2019).
\5\ The largest deals in our sample involved purchases of nursing
home chains owning hundreds of facilities already and which remained
stable in size. Both the U.S. House and Senate are considering
expanding the scope of the prevailing anti-trust laws. As example, see
https://www.cnbc.com/2021/02/04/klobuchar-unveils-sweeping-antitrust-
bill-laying-out-her-vision-as-new-subcommittee-chair-.html.
Third, this paper contributes to the emerging literature on the
industrial organization of the nursing home sector, which has received
less attention than hospitals in economics (Lin, 2015; Hackmann and
Pohl, 2018; Hackmann, 2019). Previous work has focused on the role of
competition and payment rates in determining quality. Our results imply
that owner incentives are of first-order importance, which may be
helpful for policymakers as they consider regulatory actions to improve
transparency and accountability. For example, in light of prior work
showing how PE increases performance when incentives between investors
and consumers are well-aligned, government reimbursements targeting
outcomes could potentially improve patient welfare. These issues have
become more urgent as the COVID-19 pandemic has exposed flaws in the
regulation and financing of long-term care facilities, which have
accounted for nearly 40% of U.S. deaths from the virus.\6\
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\6\ Source: The New York Times Coronavirus Tracker, as of October
2020.
The paper proceeds as follows. Section 2 provides institutional
background. Section 3 describes the data. The strategy for patient-
level analysis is explained in Section 4, and the results are in
Section 5. The facility-level estimation is in Section 6. Section 7
concludes.
2 Institutional Background
2.1 The Economics of Nursing Homes
Nursing homes provide both short-term rehabilitative stays--usually
following a hospital procedure--as well as long-term custodial stays
for patients unable to live independently. There are two unique
features of the long-term care market in the U.S. relative to other
healthcare subsectors. First, government payers (Medicaid and Medicare)
account for 75% of revenue, while private insurance plays a much larger
role in other subsectors (Johnson, 2016).\7\ Second, about 70% of
nursing homes are for-profit, which is a much larger share than other
subsectors. For example, fewer than one-third of hospitals are for-
profit. Policymakers have long been concerned about low-quality care at
nursing homes in the U.S. and for-profit ownership has often been
proposed as a causal factor (Institute of Medicine, 1986; Grabowski et
al., 2013).\8\
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\7\ Medicaid is a means-tested insurance program targeted at low
income and disabled non-
elderly individuals. It is the primary payer for custodial care and
accounts for about 60% of nursing home patient-days in our data.
Medicare is an entitlement health insurance program for individuals
older than age 65, and it covers limited short-term rehab care
following hospital inpatient care, accounting for 15% of patient-days.
\8\ This concern is frequently reflected in the popular media,
including as a reason for high death rates from COVID-19 in nursing
homes. For example, a New York Times article in December, 2020 asserted
that: ``Long-term care continues to be understaffed, poorly regulated
and vulnerable to predation by for-profit conglomerates and private-
equity firms. The nursing aides who provide the bulk of bedside
assistance still earn poverty wages, and lockdown policies have forced
patients into dangerous solitude'' (Kim, 2020).
As with any business, the economics of nursing homes are shaped by
the nature of demand, the cost structure, and the regulatory
environment. On the demand side, nursing homes serve elderly patients
but are paid by third-party, largely government payers. Over 95% of
facilities treat both Medicare and Medicaid patients (Harrington et
al., 2018). Both programs pay a prospectively set amount per day of
care for each covered patient (``per diem''), which does not
incorporate quality of care, reputation, or other determinants that
would be considered by a well-functioning market. These rates are non-
negotiable, and facilities simply choose whether they will accept
beneficiaries of these programs. Medicare fee-for-service pays much
more, at roughly $515 per patient day relative to $209 per patient day
from Medicaid.\9\ Overall profit margins are in the low single digits
(MedPAC, 2017), a topic we return to at the end of the paper. Payments
are adjusted for patient complexity, so there is an incentive to
overstate their severity--a practice known as ``up-coding.'' This makes
it difficult to use risk as an outcome.
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\9\ https://skillednursingnews.com/2019/03/medicare-advantage-eats-
into-margin-gains-for-skilled-nursing-facilities/. Medicaid still pays
more than the marginal cost of treatment per day. Hackmann (2019)
calculates that the marginal cost of treatment per-day is about $160 on
average.
Nursing homes provide institutional care and so have high fixed
costs, making the occupancy rate an important driver of profitability.
Nursing staff represent the largest component of operating cost, at
about 50% (Dummit, 2002). Broadly speaking, there are three types of
nurses. Low-skill Certified Nurse Assistants (CNAs) account for about
60% of total staff hours and provide most of the direct patient care.
Licensed Practical Nurses (LPNs) have more training and experience than
CNAs but cannot manage patients independently. Registered Nurses (RNs)
have the highest skill and experience levels, and can independently
determine care plans for patients. LPNs and RNs each account for about
20% of nurse hours. Nurse availability is crucial to the quality of
care and there is a consensus that low ratios of nursing staff to
residents are associated with higher patient mortality and other
adverse clinical outcomes (Tong, 2011; Lin, 2014). Staffing ratios are
therefore standard metrics to examine nursing home quality (Hackmann,
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2019).
Economists have long emphasized the importance of information
asymmetry between patients and healthcare providers (McGuire, 2000). It
is difficult for patients to assess nursing home quality and compare it
to available alternatives, and as discussed above, price is not a
helpful quality signal in this setting. Reputation is therefore likely
to have an unusually large influence on demand for nursing homes
(Arrow, 1963). Profit maximizing facilities should optimally invest in
building and sustaining their reputation. This creates a dynamic
incentive problem where they could generate higher profits in the
short-term by cutting patient care costs (nursing staff, for example),
but they may optimally sacrifice these short-term profits in order to
maintain their reputation and safeguard patient demand for the long-
term. It remains unclear which factor inputs affect nursing home
reputation, but evidence from prior studies suggests that patient
demand does not respond to poor quality scores on government mandated
report cards (Grabowski and Town, 2011; Werner et al., 2012).
2.2 The Economics of Private Equity Control
PE firms conduct leveraged buyouts (LBOs), in which a target firm is
acquired primarily with debt financing--which is placed on the target
firm's balance sheet--and a small portion of equity.\10\ PE is
associated with particularly high-powered incentives to maximize
profits because fund managers are compensated through a call option-
like share of the profits, employ large amounts of leverage
collateralized with target firm assets, aim to liquidate investments
within a short time frame, and do not have existing relationships with
target firm stakeholders (Kaplan and Stromberg, 2009). Specifically,
the compensation of the General Partners (GPs) who manage PE funds
stems primarily from increasing portfolio company value between the
time of the buyout and an exit, when the company is sold to another
firm or taken public. GPs typically receive 20% of profits after a
hurdle rate, which the fund's investors (Limited Partners) are
guaranteed before GPs receive any profits. GPs also receive transaction
and monitoring fees, which are not tied to performance. Overall,
however, PE managers typically do not earn returns if the business
continues as-is, motivating aggressive value-creation strategies. In
contrast, a traditional business owner running the firm as a long-term
going concern with a lower debt burden may prefer lower but more stable
profits.
---------------------------------------------------------------------------
\10\ Kaplan and Stromberg (2009) provide a detailed discussion of
the PE business model and review the academic evidence on their
effects. In the interest of brevity, we limit our discussion.
A large literature in finance beginning with Kaplan (1989) and
Kaplan and Schoar (2005) has shown that in part due to the call option-
like nature of GP compensation, PE buyouts increase productivity,
operational efficiency, and generate higher returns. Kaplan and
Stromberg (2009) argue that PE owners increase firm value through three
channels, which they call financial, governance, and operations
engineering. The first channel includes the alleviation of credit
constraints (Boucly et al., 2011), which may lead to increases in
investment and improved operations, and exploiting the favorable tax
code treatment of debt financing (Spaenjers and Steiner, 2020), which
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may increase financial stress and the chances of default.
Governance engineering includes a number of changes to the
compensation, benefits, and composition of the management team at the
target firm to align their incentives with those of the PE owners. For
example, in addition to frequently changing key managers, PE owners
also increase the equity stake of the management team and introduce
performance-based compensation (Gompers et al., 2016). Bloom et al.
(2015b) show that PE-owned firms are better managed than similar firms
that are not PE-owned.
Operations engineering refers to the more recent practice of PE
firms applying their industry expertise to add value to their
investments. PE owners identify both strategic and operational
opportunities, such as re-branding, organization restructuring,
investing in new technology, expanding to new markets, and cost-cutting
(Gadiesh and MacArthur, 2008; Acharya et al., 2013; Bernstein and
Sheen, 2016). Davis et al. (2014) show that PE buyouts are linked to
greater labor churn, the expansion of efficient operations and the
closure of inefficient operations.
Considering these changes in the context of nursing homes, the
effects on patients are theoretically ambiguous. On the one hand,
better management, stronger incentives, and access to credit may lead
to improvements in care quality. On the other hand, three forces could
adversely affect quality. The first is that cost cutting measures and a
focus on capturing subsidies could come at the expense of quality
improvement efforts. The second is that the nursing home incurs a large
debt obligation as part of the buyout, and the resulting interest
payments can reduce the cash available for care. A related additional
cost is leasing property that formerly was owned by the nursing home.
PE owners often sell real estate assets shortly after the buyout, which
generates cash that can be returned to investors. Such cash flows early
in the deal's lifecycle boost ultimate discounted returns. For example,
in one of the largest PE deals in our sample, the Carlyle Group bought
HCR Manorcare for about $6.3 billion in 2007, of which roughly one
quarter was equity and three-quarters were debt. Four years later,
Carlyle sold the real estate assets for $6.1 billion, offering
investors a substantial return on equity (Keating and Whoriskey, 2018).
Afterward, HCR Manorcare rented its facilities; the monthly lease
payments are essentially another debt obligation, and a Washington Post
investigation found that quality of care deteriorated following the
real estate sale (Keating and Whoriskey, 2018).
Finally, the third force is the relatively short-term time horizon
of PE investments,which could push managers to focus on maximizing
short-term profits even if they come at the expense of long term
reputation and performance. In the case of HCR Manorcare, the nursing
home chain was ultimately unable to make its interest and lease
payments and entered bankruptcy proceedings in the spring of 2018.
Carlyle sold its stake to the landlord.
3 Data and Descriptive Statistics
In this section we briefly summarize our data sources and provide
descriptives about the sample, including an analysis of PE targeting.
In Appendix A, we describe these elements in comprehensive detail.
3.1 Data
We obtained facility-level annual data between 2000 and 2017 from
publicly available CMS sources. In each year we observe about 15,000
unique skilled nursing facilities (we use the term ``nursing home''
interchangeably), for a total of approximately 280,000 observations.
These data include variables such as patient volume, nurse
availability, and various components of the Five Star ratings. The
ratings first appear in 2009. Fortunately, half of the PE deals in our
sample occurred after 2009.
Our second data source consists of patient-level data for Medicare
beneficiaries from 2004 to 2016. We use the Medicare enrollment and
claims files (hospital inpatient, outpatient, and nursing homes) for
the universe of fee-for-service Medicare beneficiaries. We merge these
files with detailed patient assessments recorded in the Minimum Data
Set (MDS) to obtain additional clinical insights. These data are
confidential and were accessed under a data use agreement with CMS.
They include patient enrollment details, demographics, mortality, and
information about care in nursing homes and hospitals during this
period.
In patient-level analysis, the unit of observation is a nursing
home stay for a Medicare beneficiary that begins during our sample
period, which we begin in 2005 in order to have at least one look-back
year. We consider only the patient's first nursing home stay in our
entire sample period so that we can unambiguously attribute outcomes to
one facility and make our patient sample more homogeneous. This
produces a sample of more than seven million patients over 12 years. We
are most interested in the effect on mortality, which is an
unambiguously bad outcome, has little measurement error, and is
difficult to ``game'' on the part of a facility or a government agency.
For these and other reasons, short-term mortality (with suitable risk
adjustment) has become the gold-standard measure of provider quality in
the health economics and policy literature (McClellan and Staiger,
1999). We use an indicator for death during the stay or within 90 days
following discharge, based on death dates recorded in the Medicare
master beneficiary summary file. There is a high level of short-term
mortality--one in six patients die within three months of discharge--
indicating the general morbidity of this patient cohort.
We use two measures of spending: the amount billed to Medicare for
the patient stay, and the amount for the stay plus the following 90
days, in case better quality care leads to lower subsequent spending
(both in 2016 dollars). Medicare covers the entire cost until the 21st
day of stay, at which point the patient begins paying a coinsurance.
Consequently, about 90% of total payments in our data are made by
Medicare and patients bear the remainder. We complement the mortality
analysis by examining some ancillary measures of patient well-being
using the clinical assessments. We study four outcomes that CMS uses
when computing the Five Star quality ratings for nursing homes. The
first is an indicator for the patient starting antipsychotic medication
during the stay. Antipsychotic use in the elderly is known to increase
mortality, and non-pharmaceutical interventions such as music and
breathing exercises have been shown to be more effective (Taragano et
al., 1997; Kuehn, 2005; Sink et al., 2005; Schneider et al., 2005;
Banerjee et al., 2011; Press and Alexander, 2013). The second is an
indicator for the patient's self-reported mobility score declining
during the stay. The third is an indicator for developing a pressure
ulcer. The fourth is an indicator for the patient's self-reported pain
intensity score increasing during the stay.
To identify nursing homes acquired in PE deals, we make use of a
proprietary list of transactions in the ``elder and disabled care''
sector compiled by Pitchbook Inc., a leading market intelligence firm
in this space. The deals span 2004 to 2015, so that we will have
sufficient time to evaluate outcomes. We match the target names to
individual nursing facilities using name (facility or corporate owner)
and address as recorded in the CMS data. This process yields 128 deals,
which correspond to a change in ownership to PE for 1,674 facilities.
The vast majority of deals in Pitchbook are not at hazard of matching,
as they concern assisted living or other elder care companies that are
not Medicare-accepting skilled nursing facilities. (See Appendix A for
details.)
Figure B.1 shows the number of deals in each year; the deals are
spread over time, and no part of the business cycle dominates. The
deals are also spread across PE firms. In total, our data contain 136
unique PE firms that acquired nursing homes. Most deals are syndicated
and involve multiple PE firms. Table B.1 presents the top 10 deals by
number of facilities acquired. On average, we observe PE-owned
facilities for eight years post-acquisition. Hence the results should
be interpreted as medium to long-term effects of PE ownership. It is
difficult to ascertain whether we comprehensively capture PE activity
in this sector. While there is no ``official'' tally of PE-owned
nursing homes to benchmark against, our sample size compares favorably
against an estimate of 1,876 nursing homes reportedly acquired by PE
firms over a similar duration, 1998-2008 (GAO, 2010). The PE investors
in our sample include very large funds, smaller funds, and specialized
healthcare PE investment funds. The funds which account for the
greatest number of deals are Onex, Fillmore Capital Partners, The
Hillview Group, The Carlyle Group, Cammeby International, Heritage
Partners, Lydian Capital, Formation Capital, and Oaktree.
3.2 Descriptive Statistics
Overall, PE investment in healthcare has increased dramatically in
recent decades, as shown using Pitchbook data in Panel A of Figure 1.
Panel B focuses on the Elder and Disabled Care sub-sector, which
includes the nursing homes that we study as well as assisted living and
other types of care. The shaded areas in the graphs correspond to years
after our sample ends, and indicate that deal activity continued to
accelerate beyond 2015. The bottom two panels describe the skilled
nursing facilities in our CMS data that are PE-owned. As of 2015, PE-
owned facilities represented about 9% of all nursing facilities in the
data, corresponding to an annual flow of about 100,000 patients. Note
that the large spike in the mid-2000s seen in all the graphs reflects
an economy-wide PE boom during this period, and is not specific to
healthcare. Similarly, the flat lining in Panels C and D starting in
2010 reflects the lull in deal activity due to the Great Recession.
Given the patterns in Panel B, the share of facilities that are PE-
owned is likely substantially higher today.
Table 1 Panel A presents summary statistics on key variables used
in the analysis at the facility-year level, where a facility is a
single nursing home. Panel B presents summary statistics at the unique
patient level on the final Medicare patient sample (recall we focus on
a patient's first stay). PE targets are slightly larger, have fewer
staff hours per resident, and a lower Overall Five Star rating. At the
sector level, ratings and staffing have secularly increased over time.
For staffing, this reflects more stringent standards from regulators
over time. As the PE deals occurred primarily later in the sample, it
is therefore remarkable that they have lower measures of quality on
average. Panel B shows that demographic measures are similar across the
types of facilities, such as patient age and a high-risk indicator.\11\
PE-owned facilities bill about 10% more per stay than non-PE
facilities.
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\11\ We use the Charlson Comorbidity Index, a standard measure of
patient mortality risk based on co-morbidities. We create a high-risk
indicator that is equal to one if the previous-year Charlson score is
greater than two.
We describe which characteristics are associated with buyouts in
Table A.1. Facilities in more urban counties and in states with higher
elderly population shares are more likely to be targeted.\12\ County-
level income, race, and home ownership do not predict buyouts. Chain-
owned facilities are more likely to be acquired than independent
facilities, likely reflecting the fixed costs of a PE deal. A higher
share of Medicare patients (the omitted group) is positively associated
with being targeted. Finally, the Five Star overall rating has a
negative relationship with buyouts, indicating that PE firms target
relatively low-performing nursing homes. These factors remain
statistically significant predictors when included simultaneously in
the same model, shown in column 5. These results highlight the need to
estimate the effects of PE ownership within-facility.
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\12\ The map in Figure B.2 shows that deals are not excessively
concentrated in particular areas of the country.
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4 Empirical Strategy for Patient-Level Analysis
There are two primary concerns related to measuring the causal effects
of PE ownership on patient-level outcomes. First, PE funds may target
facilities that are different in ways the econometrician cannot
observe. To address this concern, we include facility fixed effects,
eliminating time invariant differences across facilities. Second,
following a PE buyout, the composition of patients may change,
confounding the analysis. Differential customer selection following PE
ownership could reflect both supply-side channels such as changes in
advertising and hospital referrals, or patient perceptions about PE
ownership.
Recent studies have documented that nursing homes can select
patients based on patient characteristics, only some of which are
observable to CMS (Hackmann and Pohl, 2018; Gandhi, 2020). We see
evidence of changes in patient risk following PE ownership in our data.
Table B.5 Panel A presents point estimates from differences-in-
differences models that exploit variation in the timing of the PE deals
across facilities. We test for changes in patient risk (assessed at the
time of admission) following acquisition. We examine effects on a mix
of acute and chronic conditions to broadly capture changes in patient
risk. The coefficients indicate that patients are less likely to suffer
from Dementia and Alzheimers or from acute conditions like Hip
Fractures at the time of admission. However, they are also more likely
to have a Urinary Tract Infection (UTI). Figure B.3 presents the
corresponding event study plots, which generally suggest flat or
declining trends in patient risk around the time of the acquisition. We
are concerned that if there is a similar decline in unobserved patient
risk following PE ownership, it will bias downward mortality and
spending effects obtained via OLS. Therefore, we develop an instrument
for the match between patients and nursing homes.
4.1 Distance Instrument
We use a differential distance instrument (McClellan et al., 1994) to
control for endogenous patient selection into nursing homes. The
instrument exploits the well-known patient preference for nearby
healthcare providers (Einav et al., 2016; Card et al., 2019; Currie and
Slusky, 2020). This is especially true for nursing homes; for example,
Hackmann (2019) finds that the median distance between a senior's
residence and her nursing home is under 4.3 miles. This is also evident
in our data--the median and 90th percentile distances between a patient
and her nursing home are 4.6 and 18 miles, respectively. About 35% of
all patients choose the facility located closest to them (see Figure
B.4).\13\ As a result of these patterns, this instrument has been
useful in the nursing home setting to control for patient selection
(Grabowski et al., 2013; Huang and Bowblis, 2019).
---------------------------------------------------------------------------
\13\ Distance patterns remain remarkably stable over time in our
sample. Mean distance to facility is unaffectedby PE buyout, as shown
in Figure B.4D.
We compute the difference (in miles) between two distances: from a
patient's home zip code to the closest PE-owned facility zip code; and
from the patient's residence to the nearest non-PE facility zip code. A
positive value indicates the patient is closer to a non-PE facility. A
lower differential distance value implies the nearest PE-owned facility
is closer to the patient. PE ownership evolves over time as more deals
take place (and some PE funds exit their investments), creating
variation across years in differential distance for individuals
residing in the same zip code. Following convention in the literature,
we drop patients with outlier differential distance values.\14\
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\14\ Specifically, we drop patients with a differential distance
value beyond 70 miles, which is approximately the 95th percentile
(i.e., the nearest PE facility is 70 miles further than the nearest
non-PE facility). The concern here is that these patients are plausibly
located in a different market which PE facilities do not operate in,
and hence could differ in unobserved ways correlated with health or
spending outcomes. To be symmetric, we also drop (the very few)
patients who have a differential distance value below -70.
The first stage is estimated using Equation (1), and the second
stage is estimated using Equation (2). The endogenous regressor of
interest PEi,j,r,t is an indicator set to one if patient i
in Hospital Referral Region (HRR) r chooses PE-owned facility j in year
t. We instrument with linear and squared differential distance, Di
applicable to patient i based on her zip code, z, and when the nursing
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home stay began.
[GRAPHIC] [TIFF OMITTED] T1721.001
.epsOur preferred model controls for facility, aj, and
patient HRR by year fixed effects, ar,t. The vector
Xi,z denotes patient risk controls including age, indicators
for gender, marital status, dual eligible, and 17 disease
categories.\15\ We conduct multiple robustness checks, which include
adding time-varying socioeconomic variables at the patient's zipcode-
year level and omitting all controls.\16\ Standard errors are clustered
by facility to account for unobserved correlation in outcomes across
patients treated at the same nursing home.
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\15\ To construct these indicators, we use diagnoses codes recorded
in claims billed over the three months prior to the index nursing home
stay (hospital stays, ED visits, and outpatient visits).
\16\ The socioeconomic variables, from the American Community
Survey, are annual median household income, the share of the population
that are white, that are renters rather than home-owners, and that are
below the Federal poverty line.
The instrument is strongly predictive of choice of nursing home
type. The first stage results are reported in Table 2. Column 2
presents the estimates from our preferred specification. A five mile
decrease in differential distance (0.3 s.d.) increases the probability
of going to a PE-owned nursing home by 2.3 percentage points (pp), a
quarter of the mean level. The F-statistic exceeds 200, well above
conventional rule-of-thumb thresholds for weak instruments.
4.2 Instrument Assumptions and Validation Tests
IV estimation differs from randomized controlled trials because the
randomization of patients to treatment is indirect rather than
deliberate. As in all such analyses, we must rely on two untestable
identification assumptions. The first is conditional random assignment,
which requires that after conditioning on covariates, unobserved
characteristics correlated with the outcomes of interest are not
correlated with differential distance. This assumption subsumes the
exclusion restriction, that the instrument affects outcomes only
through its effect on the patient's probability of going to a PE
facility. The second assumption is monotonicity, which assumes that a
decrease in differential distance makes all patients more likely to
choose a PE-owned facility. This is true on average, but the assumption
is at the patient-level which is untestable. Monotonicity is necessary
to interpret the IV estimate as a well-defined local average treatment
effect (LATE).
An important test for randomization examines whether differential
distance is correlated with covariates, particularly those which may
affect health outcomes, such as risk. Comparing the estimates reported
in columns 1 and 2 of Table 2, the coefficients on differential
distance are nearly unaffected by including patient-level controls,
consistent with random assignment. Figure 2 Panel A visually presents
the relationship between patient risk and the instrument and indicates
little or no correlation.\17\
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\17\ We project the high-risk indicator (see Section A.2) on the
controls we use in our main regression, and collapse the residuals into
twenty bins. Similarly, we run a regression of differential distance on
the controls and collapse the residuals into twenty bins. We plot the
means of each bin, with the risk residuals on the Y-axis and distance
residuals on the X-axis. The figure also presents a fitted line and the
slope coefficient.
Additional evidence for random assignment is that patient
characteristics are similar for high and low values of differential
distance. We document this in Table 3, where we summarize 21 patient
characteristics for above- and below-median differential distance
values. The top two rows of the table show that, consistent with a
strong instrument, below-median differential distance average is 2.7
miles, while the above-median average is 27 miles. The associated
probability of going to a PE-owned facility declines from 17% to 2%.
The patient characteristics in the subsequent rows are extremely
similar across the two groups. For example, 64% of each group are
women, and about a quarter of the patients in both groups have
diabetes. While differential distance is highly predictive of going to
a PE-owned facility, it appears to randomize patients with respect to
---------------------------------------------------------------------------
observed covariates.
PE funds may strategically target nursing homes located in places
with certain desired demographic and risk profiles. We account for
stable differences in the patient catchment of facilities by including
facility fixed effects. However, it is possible that PE firms
strategically target geographic markets with desirable trends, for
example with increasing household income. To address this concern, we
show robustness to including time-varying zip code-level socioeconomic
controls. We document that these controls do not affect the first stage
in Column 3 of Table 2. The use of HRR-specific year fixed effects
further mitigates the possibility of differential market trends biasing
the effects.
A related concern may be that HRRs are too large and do not
sufficiently control for unobserved heterogeneity in trends across
markets. Hence, we also test robustness to using the more granular
market definition of Health Service Areas (HSA) and counties.\18\ There
are nearly 800 HSAs and 3,000 counties, respectively, while there are
only about 300 HRRs. Columns 4 and 5 of Table 2 present results using
these finer market definitions, respectively, with slightly smaller
estimates.
---------------------------------------------------------------------------
\18\ HSAs were developed by the National Center for Health
Statistics of the Centers for Disease Control in the mid 1990s. They
are designed to identify a single county or contiguous sets of counties
where Medicare patients seek hospital care within the area. We use a
slightly modified version developed by the SEER program of the National
Cancer Institute, available for download at https://seer.cancer.gov/
seerstat/variables/countyattribs/hsa.html.
We provide evidence consistent with the monotonicity assumption in
Figure 2 Panel B, which contains a binscatter plot of the first stage,
showing that the likelihood of going to a PE-owned facility increases
nearly linearly with differential distance. It is estimated in the same
way as Panel A described above, except that the outcome is an indicator
for the facility being PE-owned. The monotonicity assumption also
implies that the first stage should be negative when estimated on sub-
samples of patients with different characteristics. Table B.2 shows
that when we estimate the relationship between below-median
differential distance and PE ownership (a simplified first stage), we
recover coefficients that are very similar to the full-sample result
and all are significant at the .01 level for a variety of sample splits
---------------------------------------------------------------------------
by age, gender, race, and zip code income level.
Table B.2 also helps characterize compliers relative to the average
patient at a PE facility. The ratio of the first stage coefficient for
a subsample with a specific attribute to that obtained for the full
sample provides the likelihood of compliers having that particular
attribute relative to the average PE patient.\19\ Compliers appear to
have a very similar age distribution and the probability of being male,
married, or white. Intuitively, distance-based compliers are more
likely to be from a low-income zip code.
---------------------------------------------------------------------------
\19\ This follows from Bayes rule and the use of a discrete
instrument in this model of the first stage. The coefficient from a
subsample with attribute X is P(M|X) = P(X|M)P(M)/P(X) where M denotes
a marginal PE patient. Dividing by the first stage coefficient for the
full sample, P(M), gives us P(X|M)/P(X), the relative likelihood.
---------------------------------------------------------------------------
5 Patient-Level Effects
This section presents the main results of the paper. We focus on the
effects of PE ownership on short-term mortality and spending per
patient, discussing the LATE, heterogeneity in treatment effects, as
well as tests for the mechanism and robustness.
5.1 Main Effects on Mortality and Spending
Table 4 presents the results obtained by estimating Equation (2). These
models include 22 patient-level controls (described in Section 4.1),
facility fixed effects, and patient HRR- by-year fixed effects. Column
1 indicates that receiving care at a PE-owned nursing home increases
the probability of death during the stay and the following 90 days by
1.7 pp, about 10% of the mean. In the context of the health economics
literature, this is a very large effect. This estimate remains stable
in magnitude at about 10% of the mean regardless of the time horizon
studied (see Table B.3).
We calculate the implied cost in statistical value of life-years in
Table B.4 Panel A. We translate the IV coefficients into lives and
life-years lost based on the number of index stays by patients of PE-
owned nursing homes during our sample period. Accordingly, we compute
about 20,150 additional deaths due to PE ownership over our twelve-year
sample period. To estimate life-years lost, we rely on observed
survival rates for Medicare patients at all nursing homes. This leads
to an estimate of about 160,000 lost life-years.\20\ Applying a
standard estimate of statistical value of a life-year of $100,000
(Cutler and McClellan, 2001), inflated to 2016 dollars, this implies a
mortality cost of $20.7 billion.
---------------------------------------------------------------------------
\20\ As life expectancy differs substantially between men and
women, we estimate the effect separately by gender. We calculate the
average life expectancy at discharge by gender by observing the actual
life span for each patient in our data. For patients still alive at the
end of our sample period, we approximate the year of death based on
patient gender and age using Social Security actuarial tables. We
adjust this downward to account for the fact that decedents tend to be
older on average (by about 2 years). We then applied this mean life
expectancy to the number of deaths computed above and obtained the
number of life-years lost. This approach may overstate the true value
if the incremental deaths at PE facilities are of older patients. This
approach also understates the true value since we don't account for the
loss in longevity not resulting in death.
The next two columns of Table 4 Panel A consider spending per
patient. In our data, more than 90% of the billed amount is paid by
taxpayers through Medicare and patients pay the balance. The amount
billed per nursing home stay increases by 19.5% (column 2; note it is
necessary to exponentiate coefficients larger than .1 when the outcome
is logged). As Table 1 shows, on average PE-owned nursing homes bill
$14,800 per stay, while non-PE nursing homes bill $13,500. This does
not seem to reflect additional preventive care that is compensated for
by lower subsequent needs, because the total amount billed for both the
stay and the 90 days following the stay (the episode) increases by
---------------------------------------------------------------------------
about 11%.
The most important robustness test we conduct is a placebo
analysis, which probes whether spurious trends rather than the
ownership change might explain the results. We use Medicare patient-
level data from 2002-07, a period with little PE ownership of nursing
homes and little overlap with our main sample. We randomly set the PE
dummy to turn on in 2004 or 2005 for facilities that eventually were
acquired by PE firms later. Further, we discard data for any facility
starting with the year it actually got acquired. We recompute
differential distances under these ``placebo'' assignments and estimate
our main IV models. Table 4 Panel B presents these placebo estimates
and reassuringly finds small and insignificant effects, implying a lack
of differential trends prior to acquisition.
Our IV estimates imply that the reduced form effect on mortality
and spending should decline as differential distance grows larger
(i.e., relative to the nearest alternative, a PE facility is farther
away). Figure 3 visually confirms this pattern. The figure plots
coefficients from regressing each outcome on indicators for quintile of
differential distance, with the furthest quintile as the reference
group using our preferred controls as in the main specification. By
using quantile dummies, this specification is flexible and does not
impose linearity with respect to differential distance. We find the
largest effects among patients in the bottom two quintiles of
differential distance, i.e., those located nearest to PE-owned
facilities.
Results from OLS models are presented in Table B.5 and the
corresponding event studies are in Figure B.5. They suggest no pre-
trends, consistent with the parallel trends assumption that underlies
our empirical model (i.e., target facilities and control facilities
would continue on parallel trends in the absence of the buyout). We
observe a statistically significant, but much smaller increase in
mortality in the OLS model (0.3 pp). This is only one-sixth the size of
the IV estimate, consistent with unobservedly lower risk patients
matching with PE-owned facilities. In a similar vein, we also find
small, negative effects on spending (1-2% decrease) and length of stay
(not presented).
5.2 Heterogeneity in the Mortality Effect
This section explores heterogeneity both on observed attributes and on
unobserved resistance to treatment, using a Marginal Treatment Effects
(MTE) framework.
5.2.1 Observed Attributes
To assess heterogeneity in the IV analysis, we split the sample based
on observed characteristics. We first consider four groups based on
patient risk and age. We expect that higher age is associated with a
greater need for attentive but not necessarily high-skill or complex
care, for example helping patients to use the toilet and minimizing
infection risk.
Higher risk--a measure constructed from disease burdens--should be
associated with more need for high-skill, medicalized RN care. Older,
high risk patients require the most intensive and high-skill care.
Therefore, we split the sample into four groups around the median age
of 80 and around the high-risk indicator (Charlson score above two).
The results, shown in Table 5 Panel A, document that the effect on
mortality is driven by patients who are low risk, with the most robust
result among patients who are low risk but above-median age. This group
accounts for nearly half of the sample. The high risk, above-median age
group also has a large, positive coefficient, but it is noisy. In
contrast, the point estimate for high-risk but below-median age
patients is negative and marginally significant. This suggests that PE-
owned nursing homes are able to take better care of more complex
patients, especially when they are on the younger side. But lower risk
or older patients suffer.
We find positive effects among both men and women, but the effect
is larger and much more robust among female patients, who represent 65%
of the sample and are on average older. The effect is also larger among
patients from above-median income zip codes.\21\ It is also larger
among White patients. Finally, the last set of results divide the
sample into three categories corresponding to the patient's reason for
hospitalization prior to the nursing home stay; we find the largest
effect for patients who were hospitalized due to cardiovascular
disease.
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\21\ We do not observe beneficiary income directly, so we assign
individuals to above-median and below-median income neighborhoods based
on their zip code.
There is evidence that for-profit incentives generally and PE
ownership specifically are associated with lower quality of care in
more concentrated markets (Gandhi et al., 2020), so we examine in Panel
B whether the effects vary by market competition, using the Herfindahl-
Hirschman Index (HHI) of the hospital referral region (HRR). We find
that the coefficient is larger among nursing homes in below-median HHI
areas, but the coefficient is more precise among nursing homes in
above-
median HHI areas. As both coefficients are relatively close to our main
estimate, concentration does not appear to be a driving factor.
5.2.2 MTE Theory and Estimation Approach
The LATE may mask treatment effect heterogeneity across different types
of patients. For example, some patients may benefit from the type of
care that is offered by PE-owned facilities, even though we estimated
negative impacts on average for the complier group. It also ignores the
possibility of patient selection on treatment gains. The MTE framework
allows us to examine these dimensions (Heckman and Vytlacil, 2005;
Heckman et al., 2006). It enables us to compute treatment effect
parameters of economic interest such as the Average Treatment Effect
(ATE) and Treatment on the Treated (ATT). Unlike the LATE, these
parameters are not specific to the complier group and allow us to make
more general statements regarding the causal effects of PE ownership.
We denote Y0,i and Y1,i as potential outcomes
for individual i in the untreated (k = 0) and treated (k = 1) states,
respectively. Treatment in our setting is receiving care at a PE-owned
facility, PEi. We model these potential outcomes Yk,i
as a function of observed control vector Xi and dummies for
facility, Fj and market-year interactions, Rr,t.
Uk,i denotes all unobserved factors.\22\
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\22\ Following Brinch et al. (2017), we assume that the error term
Uk,i is normalized to be conditional mean zero, i.e., E[U|X
= x, F = f, R = r] = 0.
[GRAPHIC] [TIFF OMITTED] T1721.002
.epsWe then propose a latent selection model of how patients choose a
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PE-owned facility based on observed and unobserved factors.
[GRAPHIC] [TIFF OMITTED] T1721.003
.epswhere Z = (X, F, R, D, D2) is a vector including all the
controls listed above in Equation (3) and the differential distance
instruments excluded from the outcome equation, Di and
Di2. We interpret Vi as the unobserved
resistance to going to a PE-owned facility. This selection model
imposes monotonicity by using a constant parameter d for all
individuals. Following the MTE literature, we transform the selection
equation into the quantiles of the distribution of V rather than its
absolute values:
[GRAPHIC] [TIFF OMITTED] T1721.004
.epswhere F is the cumulative distribution function of Vi.
We interpret F(Z,i,d) as the propensity score, the
probability that an individual with observed characteristics Zi
chooses a PE nursing home, and denote it as P(Z). F(Vi)
represents the quantiles of unobserved resistance to treatment, and is
denoted as UD.
Omitting subscripts for simplicity, the MTE is defined as MTE(X =
x, UD = u) = E[Y1 - Y0|X = x, UD
= u]. The MTE is the treatment gain for an individual with
characteristics X = x, who is in the uth quantile of the
resistance distribution. Such individuals are indifferent to receiving
treatment when their propensity score P(Z) equals u.
We make two untestable assumptions to estimate the MTE. The first,
as in Section 4.2, is random assignment of the instrument, conditional
on observables. The second assumption is of functional form. Following
the convention in the recent MTE literature (Brinch et al., 2017;
Cornelissen et al., 2018), we assume that the MTE is additively
separable into an observed and unobserved component. This allows the
MTE to be identified over the unconditional support of P(Z) across all
values of X rather than the support of P(Z) conditional on X = x,
easing the burden of identifying variation needed from the data
(Carneiro et al., 2011).
[GRAPHIC] [TIFF OMITTED] T1721.005
.epsAnother implication of this assumption is that treatment effect
heterogeneity due to X affects the MTE curve in u only through the
intercept. The slope of the MTE curve in u does not depend on X,
facilitating estimation. The potential outcomes model described above
produces the following outcome equation as a function of observables
and P(Z) (Carneiro et al., 2011).
[GRAPHIC] [TIFF OMITTED] T1721.006
.epswhere K(p) is a nonlinear function of the propensity score. The
derivative of this outcome equation with respect to p estimates the
marginal treatment effect at X = x and UD = p (Heckman et
al., 2006).
We first estimate the selection model in Equation (4) using a
linear probability model and obtain p = Z,d. Figure 4 Panel A presents
the variation in the estimated propensity score. We collapse the data
to percentiles of differential distance, D and plot a non-parametric
fit of P(Z) values against the corresponding percentile means of D.
This shows a similar pattern first observed in Figure 2--the
probability of going to a PE-owned facility declines nearly
monotonically as differential distance increases. However, this figure
masks the full support of the distribution of P(Z), which extends over
the entire unit interval. Figure 4 Panel B highlights the overlap in
distribution of the propensity scores for treated and untreated
patients by plotting histograms for the two groups against P(Z) on the
X-axis. We use log scales on the Y-axes since there are large numbers
of observations at the two extremes of propensity score. The figure
confirms that the treated and untreated groups overlap in distributions
over nearly the entire unit interval, enabling the estimation of the
unconditional ATE without the need for extrapolation (Basu et al.,
2007). We then estimate the outcome Equation (8) below, assuming K(p)
is a polynomial in p of degree S.
[GRAPHIC] [TIFF OMITTED] T1721.007
.epsThe MTE curve is the derivative of Equation (8) with respect to
p. In our baseline model we set S = 2, but test robustness to using
higher order polynomials. Standard errors are obtained by block
bootstrap, clustering by facility.
5.2.3 MTE Results
We estimate Equation (8) and confirm the presence of selection on
unobserved resistance by testing the joint significance of the
coefficients rs on the higher order terms of the polynomial
in p (Heckman et al., 2006). The coefficient on p2 is highly
statistically significant (p value < 0.01), confirming patient
selection into PE facilities on unobserved resistance.
Figure 4 Panel C presents the MTE curve along with 90% confidence
intervals. Our primary approach uses a second degree polynomial, so the
MTE curve is linear in unobserved resistance (u). Since it is downward
sloping, there is reverse selection on treatment gains; that is,
individuals with the least resistance to going to a PE facility
experience the worst mortality effects of nearly 4 pp. In contrast,
individuals with the highest resistance experience marginally negative
(i.e., beneficial) effects. The MTE values are not statistically
significant for individuals with above median resistance to treatment.
The figure also plots the ATE, which is 1.3 pp (s.e. 1.4 pp). To test
sensitivity to the linearity assumption, we also estimate the MTE curve
with 3rd, 4th, and 5th degree polynomials. Figure B.6 Panel B shows
that the curve remains downward sloping regardless of the polynomial.
We aggregate the marginal treatment effects using the appropriate
weights to obtain various treatment effect parameters such as the
unconditional ATE and ATT (Cornelissen et al., 2016). Given the
downward sloping nature of the MTE curve, we expect the average effect
on the treated to be higher than that for the untreated. Figure 4 Panel
D presents the weights to apply to the MTE values to compute the ATT
and ATUT. Accordingly, we estimate an ATT of 3.1 pp (s.e. 0.9 pp) and
an ATUT of 1.0 pp (0.9 pp). Only the ATT is statistically significant
among the three treatment effect parameters.
There are two key takeaways from this analysis. First, the ATE
implies that a randomly chosen Medicare patient from our sample would
experience an increase of 1.3 pp in the probability of short-term
mortality if she chose a PE-owned nursing home. While about a third
lower than the LATE estimate, it nevertheless implies a large number of
deaths in a counterfactual where all Medicare short-stay patients
receive care at a PE-owned facility. Second, the MTE curve implies
reverse selection on gains and that some patients--those with greater
resistance to treatment--experience improvements in mortality if they
choose a PE-owned facility, though the negative MTE values are not
statistically significant. This pattern is consistent with the
heterogeneity in treatment effects on observed attributes. For example,
we find a large and statistically significant increase in mortality for
individuals residing in zip codes with greater than median income (see
Table 5 row 3). Individuals in richer neighborhoods are also about 20%
more likely to choose PE-owned facilities--their mean propensity score
is 12 pp versus 10 pp for patients from neighborhoods with income below
the median. In contrast, we find a smaller and statistically
insignificant effect for individuals in lower income neighborhoods.
5.3 Patient Well-Being and Mechanism Tests
If the effect on short-term mortality is related to lower patient
welfare, we expect to see consistent evidence using other well-being
measures. Therefore, we also use the IV model to assess effects on the
four clinical measures of well-being that CMS uses as outcomes for
short-stays when computing Five Star ratings (surprisingly, mortality
is not one of them). The first is whether a patient starts taking
antipsychotic drugs. As discussed in Section 3, antipsychotics are
discouraged in the elderly due to their association with mortality and
the greater efficacy of behavioral interventions. We find that going to
a PE-owned nursing home increases the chances of starting
antipsychotics by 3 pp, or 50% of the mean (Table 6 column 1). Using an
estimate from the literature on how antipsychotic medications affect
mortality, this coefficient implies that about 15% of the total effect
on mortality is potentially attributable to starting
antipsychotics.\23\
---------------------------------------------------------------------------
\23\ Several clinical studies have examined the harmful effects of
antipsychotic prescribing for the elderly. The most relevant study for
our purposes is by Schneider et al. (2005), who perform a meta-analysis
of 15 randomized controlled trials (11 from nursing homes) that studied
the effects of antipsychotics on mortality for elderly patients. They
report a 50% increase in mortality. The trials evaluated mortality at
durations averaging about 3 months, coincidentally matching our
mortality measure. Applying a 50% increase in mortality to our setting
implies an 8 pp increase in 90-day mortality on a mean of 17 pp. We
apply this elevated mortality effect to the 3 percent additional
patients at PE facilities who receive antipsychotics. This implies an
increase in mortality of 8 0.03 = 0.24 pp for PE patients on average.
We also find a positive effect on experiencing worsening mobility,
which increases by 4.3 pp, or about 8% of the mean (Table 6 column 2).
We do not find a significant effect on the third measure--developing
ulcers--though the coefficient is positive (column 3). Fourth, there is
a positive effect on increasing pain intensity of 2.7 pp, which is 10%
of the mean. Figure B.5 presents the corresponding event studies and
indicate no differential pre-trends.\24\ Overall, the evidence of
harmful effects on other measures of patient well-being are
comfortingly consistent with the estimated effects on mortality.
---------------------------------------------------------------------------
\24\ Results using OLS models are in Table B.5B. They are typically
smaller in magnitude (except ulcers), consistent with selection leading
to downward bias in OLS.
Thus far we have assumed that ownership type explains any effects
of PE buyouts. Alternatively, PE ownership could bring economies of
scale or corporatization, which are the explanation that Eliason et al.
(2020) propose for negative effects of dialysis center mergers. To test
this hypothesis, we conduct three tests in Table 7. The first adds to
our main model a control for being a chain versus an independent
facility. If our effects are explained by the ``rolling-up'' of
independent facilities into more efficient chains, the estimates should
attenuate. Instead, they are essentially unchanged. The second test
excludes the top two deals the buyouts of the very large Genesis
Healthcare and Golden Living chains (both have more than 300+
facilities). The coefficient is larger, implying that our result is not
driven by the very largest chains. The most important test is in row 4,
where we use only the top five deals to define PE ownership. In these
deals, the target chains already owned more than 100 facilities and
stayed nearly the same size over the sample period. Therefore, in this
model chain size is held constant and we evaluate the effect of a
change in ownership. Again, the effect is larger than in the full
sample. In sum, it does not seem that chain corporate structures or
---------------------------------------------------------------------------
synergies in large firms explain our results.
Another concern is whether the results are spuriously capturing the
quality difference between for-profit and nonprofit nursing
facilities.About 20% of the patients receive treatment at a nonprofit
facility. By definition these facilities are part of the control group.
We test the sensitivity of our main estimate to excluding these
facilities from the sample altogether. Row 5 presents the corresponding
results and shows that the estimate reducesabout 20% in magnitude but
remains statistically significant.
The remaining rows of Table 7 report robustness tests that vary the
controls and market definitions. If the instrument does not randomly
assign patient risk, we expect patient controls to substantially affect
the results. Instead, the results are robust to alternative controls,
consistent with random assignment. The first test in this group (row 6)
includes zip-year socioeconomic controls. The coefficients decline only
slightly. The next two rows use the more granular HSAs and counties,
respectively, to define patient markets instead of HRRs. The final row
omits all patient controls, estimating larger effects, but well within
two standard errors of the main estimate. Overall, the results are
quite stable.
6 Operational Changes
This section uses facility-level data to explore operational changes
that could help explain the adverse patient welfare effects described
in the previous section.
6.1 Empirical Strategy
For outcomes available only at the nursing home level, we cannot
instrument for patient selection and the best possible research design
therefore is differences-in-
differences. We use variants of the following specification:
[GRAPHIC] [TIFF OMITTED] T1721.008
.epsPEj,t takes a value of one if facility j is PE-owned in
year t. The coefficient of interest is b, which captures the
relationship between PE ownership and the outcome Yj,t. We
include facility (aj) and year fixed effects
(at). We retain all facilities in our preferred
specification, but the results are robust to limiting the sample to
for-profit facilities. The vector Pj,t includes three
controls for facility-level patient mix and Mj,t includes
five county-level controls for time-varying market attributes.\25\ As
there may be concern that control variables could be affected by PE
ownership, we also present results without any controls.
---------------------------------------------------------------------------
\25\ Patient mix controls: Case Mix Index (CMI) is a composite
measure of patient risk based on medical history of diagnosis or
treatment for a large number of conditions. Second, Acuity index is a
measure of patient risk computed using the patient's assessed
Activities of Daily Living (ADL) scores. In both cases, a greater value
indicates a riskier patient cohort for the nursing home. We winsorize
both the CMI and Acuity Index at the 1% and 99% level in each year. The
third control is the share of the facility's patients who are Black.
County-level controls: Herfindahl Hirschman Index (HHI) based on shares
of beds, number of for-profits, number of chain-owned, number of
hospital-based, and number of overall facilities. These are calculated
using a leave-one-out procedure from the facility-level data.
The identifying assumption is that PE targets and control
facilities would continue on parallel trends in the absence of the
acquisition. We assess whether there are differential pre-trends using
event study figures, which plot the coefficients bs from
---------------------------------------------------------------------------
estimating Equation (10) below.
[GRAPHIC] [TIFF OMITTED] T1721.009
.epsDeal Yearj,s is an indicator that is one in year s
relative to the buyout year for facility j, and zero otherwise. The
remaining terms are as defined above for Equation (9).
6.2 Results
We consider three types of operational channels. The first two
explicitly concern facility quality, while the last pertains to
financial strategies particular to the PE industry. All the results are
presented in Table 8. For each outcome, the top row of coefficients are
from specifications with only facility and year fixed effects, while
the bottom row adds the full set of patient and market controls. Event
studies are in Figures 5 and 6.
6.2.1 Compliance With Standards and Staff Availability
First, we consider compliance with care protocols in Panel A of Table
8. Our outcome of interest is the facility-level Five Star rating,
which varies from one (worst) to five (best). After PE buyouts, the
Deficiency rating declines by 0.08 points (column 1), which is about 3%
of the mean and 7% of the standard deviation (the most relevant measure
given how this variable is constructed). This rating reflects whether
the facility is satisfying care protocols such as storing and labeling
drugs properly, disinfecting surfaces, as well as other aspects of care
such as ensuring resident rights and avoiding patient abuse. The
Overall rating similarly declines (column 2). Figure 5 presents event
studies for each outcome. There are no pre-trends, consistent with the
identifying assumption, and the negative effects appear immediately
after the change in ownership and persist for at least five years.\26\
---------------------------------------------------------------------------
\26\ The Overall rating has three components: the Deficiency
rating, a Quality rating based on metrics computed using claims data
and clinical assessments, and a Staffing rating, which is based on
staffing measures evaluated in Panel B. Since we assess quality and
staffing changes more granularly, we do not present the effects on
these components, but we find negative, significant effects of equal or
larger magnitudes there as well.
In Panel B, we assess effects on nursing staff hours per patient-
day, a well-
established measure of nursing home quality that accounts for changes
in patient volume. Column 1 shows a modest decline of 0.05 hours in
aggregate staff hours (1.4% of the mean). This aggregate effect masks
larger changes for different types of nurses that offset each other.
There is a decrease in ``front-line'' caregivers (CNAs and LPNs), shown
in columns 2 and 3, respectively. Together there is a decline of around
0.09 hours for these two groups (3% of the mean). In contrast, there is
an increase in use of Registered Nurses (RNs) by about 0.04 hours (8%).
The event studies in Figure 5 again reveal no pre-trends and indicate
more immediate declines after the deal in front-line staffing, while
the increase in RN staffing appears starting in the third year after
the buyout.\27\ The increase in RN staff hours does not compensate for
the decline in lower skilled nurse hours because RNs account for a
small fraction of all staff hours. Medicare cost reports indicate that
CNAs and LPNs receive an hourly wage that is about 40% and 70%
respectively of the wage paid to RNs, which is around $35 per hour.
Unfortunately, we cannot observe whether facilities are taking cost
reduction steps such as using more part-time labor and reducing
individual shifts.
---------------------------------------------------------------------------
\27\ We report the results of robustness tests in Table B.6, which
include controls for chains, excluding the top two deals, and including
only for-profit nursing homes.
The existing literature helps to connect the effects on nurse
availability with the estimated effect on mortality. Tong (2011)
exploits an increase in minimum nurse staffing regulation in California
and finds a decline in on-site patient mortality due to greater
availability of front-line nurses. Applying her estimates in our
setting, the estimated decline in front-line nurse staffing predicts an
increase in mortality of 0.25 pp.\28\ The findings on increased use of
antipsychotics and lower nurse availability may be related. Grabowski
et al. (2011) note that antipsychotics are believed to substitute for
nurse care and show that when nursing homes increase wages,
inappropriate use of antipsychotics decreases. Therefore, it is
intuitive that lower staffing--in particular low-skill staffing--would
be associated with increases in adverse conditions related to lack of
attention, such as more use of antipsychotics and lower mobility. The
two channels additively predict an increase in mortality of 0.5 pp in
our setting (about 30% of our mortality effect). However, this may be
an underestimate if they produce larger effects when they interact.
---------------------------------------------------------------------------
\28\ Tong (2011) reports a 15% decline in mortality due to an
increase in nurse availability of one hour per resident-day. Since we
estimate a decline of 0.09 hours, this predicts an increase of 0.09
15 = 1.4% of the mean, or 0.24 pp. More recently, Ruffini (2020)
exploits variation in minimum wage requirements to isolate the effects
of nurse staffing changes on quality and also finds mortality effects.
The increase in RN availability is consistent with the negative
effects on mortality being driven by older rather than more complex
patients. RN staff are most relevant for the more medicalized aspects
of care, while front line nurses support daily living activities such
as preventing infections and turning patients in bed. One possibility
is that managers may have looked for ways to cut overall labor costs
while changing the mix of nursing staff capability to maintain quality
and patient experience, as RNs are crucial to nursing home quality
(Zhang and Grabowski, 2004; Lin, 2014). An alternative explanation is
the regulatory focus on RNs. For example, CMS uses the availability of
RNs to determine eligibility for Medicare reimbursement.\29\ Given the
tight regulatory scrutiny of RN availability, it is difficult to reduce
staffing levels in this category.
---------------------------------------------------------------------------
\29\ Specifically, such facilities are defined by having ``an RN
for 8 consecutive hours a day, 7 days a week (more than 40 hours a
week), and that there be an RN designated as Director of Nursing on a
full time basis.'' See https://www.cms.gov/Regulations-and-Guidance/
Guidance/Manuals/Downloads/som107c07pdf.pdf.
To explore whether the declines in staff availability and quality
are related, we compare changes in staff availability and Five Star
ratings within target facilities around the PE buyout event. This
analysis recovers correlations and does not imply causality, so we
present the raw data in bin-scatter plots. Figure B.7 shows the change
in Five Star rating over the three years around PE acquisition on the
Y-axis against the change in aggregate staff hours per patient day
during the same period on the X-axis. The plots show that facilities
which experienced larger declines in staff availability also
experienced greater declines in ratings. The patterns are consistent
across rating types and suggest that cuts to nursing staff may be an
important channel to explain the quality declines.
6.2.2 Finances and Operations
Our final analysis uses CMS cost reports to analyze key sources of
expenditure related to the PE business model. We begin by noting that
nursing homes are widely known to have relatively low and regulated
profit margins, often cited at just 1-2%.\30\ Our data on nursing home
cost reports submitted to CMS indicate that nursing homes report
negative operating margins on average, and PE-owned nursing homes are
not on average more profitable. In unreported analysis, we see no
effect of buyouts on net income or overall revenue or costs. This
raises the question of how PE firms create value from nursing home
investments.
---------------------------------------------------------------------------
\30\ http://www.medpac.gov/docs/default-source/data-book/
jun17_databookentirereport_sec.
pdf.
---------------------------------------------------------------------------
There are three types of firm expenditures that the academic
literature and popular press particularly associates with profits for
PE owners. The first is what are often termed ``monitoring fees''
charged to portfolio companies. In the CMS cost reports, these are
listed as ``management fees''--charges to the nursing home for being
owned and managed by a PE firm.\31\ Metrick and Yasuda (2010) note that
these are thought to be between 1-5% of EBITDA. Our data suggest that
they increase over time after buyouts, as shown in Figure 6 Panel A,
where the fees are flat before the buyout, and then rise dramatically
afterwards. Table 8 Panel C column 1 indicates that on average,
management fees increase by 7.7% after acquisition (we exponentiate
coefficients in this panel as the outcomes are in logs).
---------------------------------------------------------------------------
\31\ In their summary of buyout fund economics, Metrick and Yasuda
(2010) write that ``we think of monitoring fees as just another way for
BO funds to earn a revenue stream.'' These fees should not be confused
with the usual 2% of fund value that General Partners earn each year
for managing Limited Partners' capital, before profits from
investments.
The second type of expenditure is lease payments. The value of
underlying real estate is frequently cited as a reason that nursing
homes and other typically low-margin assets can be profitable
investments, because the investor can sell the real estate to a related
company or to a third party (Dixon, 2007; Keating and Whoriskey, 2018;
Brown, 2019). Cash from the real estate sale can be disbursed as
profits to the PE fund. A cash inflow early in the life of the
investment is particularly beneficial to the fund's Internal Rate of
Return, a key performance metric. The nursing home assumes the
obligation of future rent payments. As an example, a New York Times
---------------------------------------------------------------------------
report on the nursing home industry notes that:
[PE] investors created new companies to hold the real estate
assets because the buildings were more valuable than the
businesses themselves, especially with fewer nursing homes
being built. Sometimes, investors would buy a nursing home from
an operator only to lease back the building and charge the
operator hefty management and consulting fees (Goldstein et
al., 2020).\32\
---------------------------------------------------------------------------
\32\ Two examples further illuminate these types of transaction.
First, the HCR Manorcare deal discussed in Section 2.2, where the
chain's real estate assets were spun off and sold shortly after the
acquisition by the Carlyle Group. Second, at a Congressional hearing
the executive director of the Long-Term Care Community Coalition said
``more and more with entities buying up nursing homes, they have no
experience in the business, they sell out the underlying property''
(Brown, 2019).
Consistent with this strategy, column 2 shows that facility building
lease payments increase dramatically by about 75% after PE
acquisitions. Figure 6 Panel B confirms the lack of pre-trends and the
---------------------------------------------------------------------------
increase post-buyout.
The third type of expenditure is interest on debt. While not a
direct source of PE profits, debt is tightly related to the overall PE
model for creating value. Metrick and Yasuda (2010) note that the ratio
of debt to equity in a buyout deal is typically around 5:1. The
interest payments become a cost to the portfolio company. In Figure 6
Panel C, we see that like the previous two outcomes, interest payments
are flat before the buyout and then rise dramatically afterwards.
Column 3 indicates that the increase is about 325%.
Finally, we find that cash on hand declines after the buyout by
38%. Unlike the other outcomes, the event study in Figure 6 Panel D
indicates that cash on hand initially increases after the buyout as
profits increase and cash is injected, perhaps to invest in efficiency
improvements. However, as the strategies for returning profit to the
investors are implemented, such as selling the real estate and thus
requiring the operator to take on lease payments, the cash on hand
turns negative. This could make the nursing home less well-equipped to
manage sudden shocks such as, for example, needing to buy personal
protective equipment following an infectious disease breakout.
Taking the results on nurse availability together with the
estimated effects on interest, lease, and management fees payments, we
infer that PE ownership shifts operating costs away from staffing
towards costs that are profit drivers for the PE fund. To our
knowledge, this paper offers the first instance in the literature on PE
in which these three profit drivers have been documented
systematically.
The final outcome we explore is patient capacity and volume. Table
B.7 column 1 finds no measurable change in the number of beds, which
may partly reflect state regulations restricting expansions. Admissions
increase by 3.5%, or 6.5 patients per year for the average facility
(column 2). However, we interpret this effect with caution since the
corresponding event study suggests a pre-trend (Figure B.8B). The
apparent disconnect between demand and quality of care may reflect
information frictions in observing nursing home quality, as discussed
earlier (Arrow, 1963; Grabowski and Town, 2011; Werner et al., 2012).
Higher admissions raise the question of whether PE ownership
increases overall access to nursing home care, providing care for
individuals who would not otherwise have gone to a nursing home. To
test whether this is the case, we assess the effects of PE entry into a
nursing home market, using the HRR definition. Table B.7 column 3 shows
that there is no effect of initial PE entry on admissions at the market
level, corroborated by flat patterns in the event study (Figure B.8C).
Hence, the data are more consistent with the facility-level admissions
increase reflecting business stealing.
7 Conclusion
This paper studies PE buyouts in healthcare, an important sector where
PE activity has increased dramatically, generating policy debate.
Nursing homes are a useful setting because they have particularly high
levels of for-profit ownership and subsidy and have experienced
extensive PE investments. In an instrumental variables design
incorporating facility fixed effects, we address both targeting and
patient selection challenges to identification. We find that going to a
PE-owned facility increases 90-day mortality by about 10% for short-
stay Medicare patients, while taxpayer spending over the 90 days
increases by 11%. Furthermore, we document declines in nurse
availability per patient and in measures of compliance with Medicare's
standards of care. We also find a corresponding increase in operating
costs that tend to drive profits for PE funds.
There are many channels for future work. Although our results imply
PE ownership reduces productivity of nursing homes, it may have more
positive effects in other sectors of healthcare with better functioning
markets. Beyond healthcare, there has been significant PE investment in
sectors such as education, defense and infrastructure, which like
healthcare rely on high levels of government subsidy but are
characterized by opaque product quality. Further work is needed to
determine how government programs can be redesigned to align the
interests of PE-owned firms with those of taxpayers and consumers.
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Figures and Tables
[GRAPHIC] [TIFF OMITTED] T1721.010
.eps Note: This figure shows PE deals in healthcare over time.
Panels A and B present the total capital invested (left axis) and
number of transactions (right axis) by PE firms in healthcare and
eldercare, by year. Panels C and D focus on the number of active
nursing homes owned by PE firms in each year. Panel B presents the
number of PE-owned facilities (left axis) and patients admitted at
these facilities (right axis). Note that the total number of facilities
ever bought by PE firms is larger (1,674) than what is plotted here
since some of these facilities closed or went back to non PE ownership
over time. Panel D presents these trends as a percentage of total
number of facilities and patients admitted, respectively.
[GRAPHIC] [TIFF OMITTED] T1721.011
.eps Note: This figure presents scatter plots of patient
characteristics against differential distance to the nearest PE
facility. The independent variable is the difference in distance (in
miles) of the nearest PE nursing home to the nearest non-PE nursing
home for the patient. The dependent variable in Panel A is an indicator
for the patient to have a Charlson Co-morbidity Index (based on
diagnoses recorded in hospital inpatient and outpatient claims over the
3 months before admission to nursing home) greater than 2, and in Panel
B is an indicator for the nursing home being PE-owned. The data was
collapsed into 20 equal sized bins and we plot the means of residuals
in each bin that were obtained from models including facility and
patient HRR x Year fixed effects, and patient demographics: age, race,
gender, marital status, and an indicator if patient is dual eligible.
The figures also present quadratic fitted lines for these plots. Each
plot also presents the slope coefficient (per 10 miles of differential
distance) with the corresponding standard error. Standard errors are
clustered by facility.
[GRAPHIC] [TIFF OMITTED] T1721.012
.eps Note: This figure presents results from reduced form
regressions for patient-level outcomes on the instrument, differential
distance. Each blue point in the figure represents a coefficient bs,
obtained by estimating the equation Yi = am,t +
aj + Ss=25b 1(Qdd = s)i +
g1 Xi + +ei, where 1(Qdd = s)i
is an indicator for the qth quintile of differential distance. The
highest quintile group, i.e., individuals relatively furthest away from
a PE facility, is the reference group. Log total payment in Panel B
refers to the total payment for the index nursing home stay. Standard
errors are clustered by facility.
[GRAPHIC] [TIFF OMITTED] T1721.013
.eps Note: This figure presents results pertaining to Marginal
Treatment Effects (MTE) analysis using the Medicare patient-level data.
Panel A presents the ``first stage'' fit of predicted probability of
treatment or propensity score, w.r.t the instrument. Panel B presents
the overlap in distributions of PE and non-PE groups by propensity
score. This plot uses a log scale due to the large number of non-PE
patients with low propensity. Appendix figure B.6A presents the
corresponding plot using a linear scale. Panel C presents the MTE curve
with 90% confidence intervals obtained using block bootstrap and the
Average Treatment Effect (ATE) estimate. Panel D presents the weights
for the Average Treatment on the Treated (ATT) and Average Treatment on
the Untreated (ATUT) and the corresponding estimates. Section 5.2.2
presents details of the MTE estimation.
[GRAPHIC] [TIFF OMITTED] T1721.014
.eps Note: This figure presents event studies on quality of care
measures (Five Star ratings) and Staffing around the time a nursing
home experiences a PE buyout. Each point in the figures represents the
coefficient bs obtained by estimating Equation (10) as
discussed in Section 6. Year = -2 is the omitted point. In Panels A and
B, we present effects on the Five-star ratings awarded by CMS -
deficiencies identified by independent contractors in audits and
overall rating, respectively. A negative effect on ratings implies a
decline in quality. Panels C to F present results on nurse staffing
per-patient for all staff, nurse assistants, licensed nurses, and
registered nurses respectively. All models include facility and year
fixed effects, patient mix and market controls, as described in Section
6.1. All dependent variables are winsorized at 1 and 99% level.
Standard errors are clustered by facility.
[GRAPHIC] [TIFF OMITTED] T1721.015
.eps Note: This figure presents event studies on facility finances
around the time a nursing home experiences a PE buyout. Each point in
the figures represents the coefficient bs obtained by
estimating Equation (10) as discussed in Section 6. Year = -2 is the
omitted point. Panels A to D present results on the log of management
fee cost, building lease cost, interest cost, and cash on hand,
respectively. All models include facility and year fixed effects,
patient mix and market controls, as described in Section 6.1. All
dependent variables are winsorized at 1% and 99% levels. Standard
errors are clustered by facility.
Table 1: Descriptive Statistics
----------------------------------------------------------------------------------------------------------------
All Not PE-owned PE-owned
----------------------------------------------------------------------------------------
Mean SD Count Mean Count Mean Count
----------------------------------------------------------------------------------------------------------------
A. Facility Level
Attributes
Overall Five-Star 3.17 1.30 138,204 3.20 127,441 2.83 10,763
Rating
Deficiency Five-Star 2.84 1.25 138,204 2.86 127,441 2.62 10,763
Rating
Staff Hours per Pat. 3.59 1.49 284,108 3.60 271,118 3.38 12,990
Day
Nurse Assistant Hours 2.28 0.79 284,108 2.29 271,118 2.06 12,990
per Pat. Day
Licensed Nurse Hours 0.82 0.46 284,108 0.82 271,118 0.82 12,990
per Pat. Day
Registered Nurse Hours 0.46 0.57 284,108 0.46 271,118 0.49 12,990
per Pat. Day
Number of Beds 104.48 56.60 284,108 104.11 271,118 112.34 12,990
Admissions 184.16 166.97 284,108 180.40 271,118 262.47 12,990
Ratio Black 0.10 0.17 284,108 0.10 271,118 0.12 12,990
Ratio Medicaid 0.60 0.24 284,104 0.60 271,114 0.60 12,990
Ratio Medicare 0.15 0.17 284,104 0.15 271,114 0.18 12,990
Ratio Private 0.25 0.19 284,104 0.25 271,114 0.22 12,990
Management Fees (2016$) 7,076 120,673 231,795 6,001 219,231 25,833 12,564
Building Lease (2016$) 5,860 80,223 231,826 4,825 219,262 23,919 12,564
Interest Expense 12,911 163,562 231,855 5,588 219,291 140,733 12,564
(2016$)
Cash on Hand (2016$) 1,110,000 10,600,000 231,811 1,150,000 219,257 516,772 12,554
----------------------------------------------------------------------------------------------------------------
B. Medicare Patient
Attributes
Age 81.41 8.10 7,365,953 81.46 6,668,539 80.92 697,414
Female 0.64 0.48 7,365,953 0.64 6,668,539 0.62 697,414
Black 0.08 0.27 7,365,953 0.08 6,668,539 0.09 697,414
White 0.88 0.32 7,365,953 0.88 6,668,539 0.88 697,414
Married 0.34 0.47 7,365,953 0.34 6,668,539 0.35 697,414
Charlson Score 0.27 0.44 7,365,953 0.27 6,668,539 0.29 697,414
(Previous) > 2
Cardio-Vascular Disease 0.18 0.39 7,365,953 0.18 6,668,539 0.18 697,414
Injury 0.19 0.39 7,365,953 0.19 6,668,539 0.19 697,414
Other 0.63 0.48 7,365,953 0.63 6,668,539 0.63 697,414
Dual Eligible 0.18 0.38 7,365,953 0.18 6,668,539 0.17 697,414
Differential Distance 14.87 16.70 7,365,953 16.21 6,668,539 2.11 697,414
(Miles)
Mortality (Stay + 90 0.17 0.38 7,365,953 0.17 6,668,539 0.18 697,414
Days)
Starts Anti-Pyschotics 0.06 0.23 7,365,953 0.06 6,668,539 0.06 697,414
Mobility Reduces 0.54 0.50 7,365,953 0.53 6,668,539 0.62 697,414
Develops Ulcers 0.09 0.28 7,365,953 0.09 6,668,539 0.09 697,414
Pain Intensity 0.27 0.45 7,365,953 0.27 6,668,539 0.30 697,414
Increases
Amount Billed per 13,600 12,200 7,365,953 13,500 6,668,539 14,800 697,414
Patient Stay (2016$)
Amount Billed per 21,100 20,100 7,365,953 20,900 6,668,539 22,600 697,414
Patient Stay + 90 Days
(2016$)
----------------------------------------------------------------------------------------------------------------
Note: This table presents descriptive statistics for key variables used in the analysis. Panel A presents
descriptives on facility-level data for all nursing homes over the years 2000-17 while Panel B presents
patient-level data for Medicare patients with index stays over the years 2005-16. A unit of observation is a
facility-year in Panel A and a unique patient in Panel B (since we retain only the first stay per patient).
Columns 1, 2 and 3 present means, standard deviations and number of observations for the full sample. We
categorize facilities into two groups. Columns 4 and 5 present means and number of observations at facilities
that never experienced a PE acquisition or before PE acquisition during our sample period. Columns 6 and 7
present corresponding values for facilities in the post-buyout period. For most variables, about 10% of the
observations pertain to facilities that experienced a PE acquisition. Sample sizes differ across variables in
Panel A since they were sourced from multiple sources or in some cases were reported only for more recent
years. In Panel A, all continuously varying variables were winsorized at the 1% and 99% levels. We compute the
Charlson Co- morbidity Index using co-morbidities diagnosed in hospital inpatient and outpatient claims (first
10 dx codes) over the 3 months prior to, but not including, the index stay. Spending values in Panel B are
winsorized at the 99% level and deflated to be in 2016 dollars. ``Total'' billing includes hospital inpatient,
outpatient including emergency department, and nursing home stay spending over the 90 days following discharge
from the index stay and includes the index stay. The following patient-level variables were sourced from the
Minimum Data Set (MDS): marriage, antipsychotics, mobility, and pressure ulcers. Medicare patients that could
not be merged into the MDS (94% match rate) were dropped from the sample. Facilities with less than 100
Medicare patients over the entire period were omitted from the patient-level sample. If any of the MDS
variables was missing, then we set the respective indicator to zero. We exclude patients facing a differential
distance of greater than 70 miles, approximately the 95th percentile value, or below -70 miles.
Table 2: Patient-Level Analysis: First Stage
----------------------------------------------------------------------------------------------------------------
(1) 1(PE) (2) 1(PE) (3) 1(PE) (4) 1(PE) (5) 1(PE)
----------------------------------------------------------------------------------------------------------------
Differential Distance -0.0480*** -0.0480*** -0.0479*** -0.0454*** -0.0419***
(In 10 Miles) (0.002) (0.002) (0.002) (0.002) (0.002)
(Differential Distance)\2\ 0.0062*** 0.0063*** 0.0062*** 0.0059*** 0.0055***
(In 10 Miles) (0.000) (0.000) (0.000) (0.000) (0.000)
Market Controls Y
Patient Controls Y Y Y Y
Facility FEs Y Y Y Y Y
Patient FEs Level HRR Year HRR Year HRR Year HSA Year County Year
Observations 7,365,934 7,365,934 7,358,129 7,365,752 7,365,246
Y-Mean 0.09 0.09 0.09 0.09 0.09
F-Stat 224 224 222 220 203
----------------------------------------------------------------------------------------------------------------
Note: This table presents estimates of the relationship between PE ownership of the nursing home and the
patient's differential distance. Each cell presents the coefficient b obtained by estimating Equation (1). The
independent variable is the difference in distance (both linear and quadratic, in 10 miles) to the nearest PE
nursing home and the nearest non-PE nursing home for the patient. This is calculated based on distances
between the respective zip code centroids. The outcome variable is an indicator for whether the nursing home
serving the patient is PE-owned (=1 if PE-owned, 0 otherwise). Column 1 controls for facility and patient
market (Hospital Referral Region) Year fixed effects. Column 2 (our preferred specification) adds controls
for patient risk controls (indicators for 17 pre-existing conditions used to define the Charlson Co- morbidity
Index inferred from claims over the three months prior to admission, and sex, age, race, marital status, and
an indicator if patients are dual eligible). Column 3 adds controls for patient zip-year characteristics:
median household income, the shares of the population that are white, that are renters rather than home-
owners, that are below the Federal poverty line, and that are enrolled in the medicare advantage program.
Column 4 uses the same controls as in col. 2 but defines patient market using a narrower market definition:
Health Service Area (HSA) instead of HRR. Column 5 uses the same controls as in col. 2 but defines patient
market using a narrower market definition: County instead of HRR. Standard errors are clustered by facility.
Table 3: Balance of Patient Characteristics
------------------------------------------------------------------------
(1) DD < (2) DD >
Patient Attribute Median Median
------------------------------------------------------------------------
Differential Distance 2.70 27.04
PE-owned Nursing Home 0.17 0.02
Age 81.40 81.42
Female 0.64 0.64
Black 0.09 0.07
Married 0.35 0.34
Dual Eligible 0.16 0.19
AMI 0.08 0.08
Congestive Heart Failure 0.22 0.24
PVD 0.05 0.05
CEVD 0.13 0.14
Dementia 0.04 0.05
COPD 0.21 0.23
Rheumatoid Arthritis 0.03 0.03
Peptic Ulcer 0.02 0.02
Mild Liver Disease 0.01 0.01
Diabetes 0.21 0.22
Diabetes + Complication 0.04 0.04
Paraplegia 0.03 0.03
Renal Disease 0.14 0.13
Cancer 0.09 0.08
Severe Liver Disease 0.01 0.01
Metastatic Cancer 0.04 0.04
AIDS 0.00 0.00
Number of Patients 3,683,135 3,682,818
------------------------------------------------------------------------
Note: This table presents the balance in patient attributes with respect
to the instrument: differential distance. We divide patients into two
groups based on whether their differential distance is below or above
the median value (8.9 miles). Recall that differential distance (DD)
is the difference between distance to the nearest PE nursing home and
the nearest non-PE nursing home for the patient. Column 1 presents the
means of patient characteristics for patients with DD below the median
value, while Column 2 presents the means for patients with DD greater
than the median. Characteristics include four demographics and 17 pre-
existing co-morbidity indicators used to compute the Charlson Co-
morbidity Index. Paraplegia includes both partial and complete
paralysis. We generated indicators for the 17 disease groups using the
``charlson'' command in Stata, available at http://fmwww.bc.edu/RePEc/
bocode/c/charlson.html. We considered diagnosis codes on hospital
inpatient and outpatient claims over the 3 months prior to, but not
including, the index nursing home stay.
Table 4: Patient-Level Analysis: IV Results
----------------------------------------------------------------------------------------------------------------
(2) Log Amount (3) Log Amount
(1) Mortality Billed Per Patient Billed Per Patient
(Stay + 90 Days) Stay Stay + 90 Days
----------------------------------------------------------------------------------------------------------------
A: Main Results
--------------------------------------------------------------
1(PE) 0.0168** P(0.007) 0.1777*** P(0.028) 0.1054*** P(0.024)
Observations 7,365,934 7,365,934 7,365,934
Y-Mean 0.17 9.07 9.57
F-Stat 224 224 224
--------------------------------------------------------------
B: Placebo Analysis
--------------------------------------------------------------
1(PE) 0.006 P(0.004) -0.015 P(0.018) -0.016 P(0.016)
Observations 7,159,535 7,159,535 7,159,535
Y-Mean 0.18 9.01 9.51
F-Stat 441 441 441
----------------------------------------------------------------------------------------------------------------
Note: This table presents estimates of the relationship between PE ownership and patient health and spending. In
Panel A, each cell presents the coefficient b obtained by estimating Equation (2) by 2SLS. The independent
variable is an indicator for the patient being admitted to a PE nursing home, instrumented by differences in
distance to the nearest PE and non-PE facility. Panel B presents results from a placebo analysis of the
relationship between private equity ownership and patient health and spending. For this analysis, we use data
over 2002-07, a period with very little actual PE ownership and which has little overlap with the main
analysis sample. We assign placebo PE acquisition in 2004 to facilities that were eventually acquired before
2008 and 2005 to facilities acquired in and post 2008 by PE firms. Accordingly we re-Pcompute differential
distance values taking into account these placebo acquisitions. We present effects for claims-based patient
quality outcomes - patient death within 90 days of discharge from the index stay, and total amount billed
(2016$). All regressions include facility and patient HRR Year fixed effects, and patient risk controls.
Patient risk controls include age, race, gender, marital status, indicators for 17 pre-Pexisting conditions
used to compute the Charlson Index, and an indicator if patients are dual eligible. Standard errors are
clustered by facility.
Table 5: Heterogeneity in Patient Mortality
------------------------------------------------------------------------
(1) (2) (3) (4) (Std.
Observations Mean Coefficient Errors)
------------------------------------------------------------------------
A: Patient Level
------------------------------------------------------------------------
1. Age and
Risk
Low Risk, 2,052,655 0.08 0.0186* (0.011)
65-80
High Risk, 881,854 0.24 -0.0346* (0.021)
65-80
Low Risk, 3,326,940 0.16 0.0319*** (0.011)
80+
High Risk, 1,104,387 0.29 0.023 (0.020)
80+
2. Gender
Male 2,640,611 0.21 0.0105 (0.012)
Female 4,725,295 0.14 0.0210** (0.008)
3. Benefici
ary Zip
Income
Income < 3,681,687 0.18 0.0122 (0.010)
Median
Income > 3,684,035 0.16 0.0262** (0.011)
Median
4. Race
White 6,483,451 0.17 0.0206*** (0.008)
Other 881,923 0.16 -0.0219 (0.023)
5. Reason
for
hospitaliz
ation
Cardio- 1,340,956 0.20 0.0298* (0.016)
Vascular
Injury 1,409,910 0.11 0.0236* (0.014)
Other 4,615,012 0.18 0.0096 (0.009)
------------------------------------------------------------------------
B: Market Level
------------------------------------------------------------------------
1. Hirfinda
hl
Hirschman
Index
HHI < 3,706,810 0.16 0.0223 (0.020)
Median
HHI > 3,659,035 0.18 0.0144* (0.008)
Median
------------------------------------------------------------------------
Note: This table presents heterogeneity in the effects of PE ownership
on patient mortality. Column 1 presents the sample size and Column 2
presents the mean. Columns 3 and 4 present the corresponding
coefficient b and its standard error obtained by estimating Equation
(2) by 2SLS. The independent variable is the indicator for a patient
being admitted to a PE nursing home, instrumented by differences in
distance to the nearest non-PE and PE nursing home. The outcome
variable is an indicator for patient death within 90 days of discharge
from the index stay. Panel A explores heterogeneity on patient level
factors--by dividing patients into 4 groups based on severity of pre-
existing co-morbidities (high risk = Charlson Index greater than 2)
and age (greater than 80) in row 1, gender in row 2, median income in
the patient's zip code in row 3, race in 4, and the reason for
hospitalization prior to the nursing home stay in row 5. Panel B
explores heterogeneity based on market factors--dividing markets below
and above the median Hirfindahl Hirschman Index (HHI). We computed the
HHI using market shares in terms of beds as observed in 2003-04, where
the HRR in which the nursing home is located is considered its market.
All models include facility and patient HRR year fixed effects. We
additionally control for the usual patient risk controls as in the
main regression. Standard errors are clustered by facility.
Table 6: Patient Well-being
----------------------------------------------------------------------------------------------------------------
(1) 1(Starts (4) 1(Pain
Anti- (2) 1(Mobility (3) 1(Develops Intensity
Psychotics) Decreases) Ulcers) Increases)
----------------------------------------------------------------------------------------------------------------
1(PE) 0.0297*** 0.0425*** 0.0065 0.0273*
(0.006) (0.011) (0.008) (0.016)
Observations 7,365,934 7,365,934 7,365,934 7,365,934
Y-Mean 0.06 0.53 0.09 0.27
----------------------------------------------------------------------------------------------------------------
Note: This table presents estimates of the relationship between PE ownership and measures of patient well-being
obtained from clinical assessments. Each cell in the first row presents the coefficient b obtained by
estimating Equation (2). The independent variable is an indicator for the patient being admitted to a PE
nursing home, instrumented by differences in distance to the nearest PE and non-PE facility. All models
include facility and patient HRR Year fixed effects. We additionally control for the usual patient risk
controls as in the main regression. The independent variable is an indicator for whether a nursing home is
private equity-owned (=1 if PE-owned, 0 otherwise) starting in the next year from the deal announcement date.
We present results for patient level outcomes--an indicator for patient starting anti-psychotics, decrease in
patient mobility, developing/worsening pressure ulcers, and increase in pain intensity. These variables take
value one if this condition is not flagged for the patient in the initial assessment, but is flagged at some
point during the stay. Standard errors are clustered by facility.
Table 7: Patient-Level Analysis: Robustness
----------------------------------------------------------------------------------------------------------------
(2) Log Amount (3) Log Amount
(1) Mortality (Stay Billed Per Patient Billed Per Patient
+ 90 Days) Stay Stay + 90 Days
----------------------------------------------------------------------------------------------------------------
1. Base Specification
1(PE) 0.0168** (0.007) 0.1777*** (0.028) 0.1054*** (0.024)
2. Chain Controls
1(PE) 0.0169** (0.007) 0.1777*** (0.028) 0.1055*** (0.024)
3. W/O Top 2 Deals
1(PE) 0.0309*** (0.011) 0.2309*** (0.045) 0.1429*** (0.037)
4. Top 5 Deals Only
1(PE) 0.0349*** (0.012) 0.2469*** (0.046) 0.1510*** (0.039)
5. Only For Profits
1(PE) 0.0138** (0.007) 0.1474*** (0.026) 0.0836*** (0.021)
6. Zip-Year Controls
1(PE) 0.0150** (0.007) 0.1760*** (0.028) 0.1029*** (0.024)
7. HSA-Year FEs
1(PE) 0.0211*** (0.008) 0.1800*** (0.030) 0.1130*** (0.025)
8. County-Year FEs
1(PE) 0.0221** (0.010) 0.1430*** (0.034) 0.0832*** (0.029)
9. No Controls
1(PE) 0.0296*** (0.008) 0.2391*** (0.030) 0.1131*** (0.024)
Observations 7,365,934 7,365,934 7,365,934
Y-Mean 0.17 9.07 9.57
----------------------------------------------------------------------------------------------------------------
Note: This table presents results from specification checks on the relationship between PE ownership and patient
health and spending. Each cell presents the coefficient b obtained by estimating Equation (2) by 2SLS. The
independent variable is an indicator for the patient being admitted to a PE nursing home, instrumented by
differences in distance to the nearest PE and non-PE facility. We present effects for patient death within 90
days of discharge from the index stay, the log of the total amount billed for the stay and the log of the
amount billed for the stay and across hospital inpatient, outpatient and nursing home over the 90 days
following the stay (2016$). All models include facility fixed effects. The first six rows include HRR year
fixed effects, the seventh row uses Health Service Areas (HSA), and the eighth row uses county to define
patient market instead of HRR. The second row controls for facility being part of a chain. The third row
calculates the results excluding all data for chains involved in the 2 largest PE deals. The fourth row limits
the PE group to only the facilities bought in the 5 largest PE deals. The fifth row limits the sample only to
for-profit facilities. The sixth row includes patient zip controls: median household income, the shares of the
population that are white, that are renters rather than home-owners, that are below the federal poverty level,
and that are enrolled in Medicare Advantage program. The first eight rows includes patient risk controls: age,
race, gender, marital status, indicators for 17 pre-existing conditions used to compute the Charlson score,
and an indicator if patients are dual eligible. The ninth row presents coefficients from a model with fixed
effects only. Standard errors are clustered by facility.
Table 8: Mechanisms and Operational Changes
----------------------------------------------------------------------------------------------------------------
A: Five Star Rating
---------------------------------------------------------------------------
(1) (2)
Deficiency Overall
Rating Rating
----------------------------------------------------------------------------------------------------------------
1(PE) -0.075** -0.079**
(No Control) (0.037) (0.036)
1(PE) -0.077** -0.082**
(With Control) (0.037) (0.036)
Observations 138,051 138,051
Y-Mean 2.9 3.2
----------------------------------------------------------------------------------------------------------------
B: Staff Per Patient Day
---------------------------------------------------------------------------
(1) (2) (3) (4)
All Staff Nurse Assistant Licensed Nurse Registered Nurse
----------------------------------------------------------------------------------------------------------------
1(PE) -0.050*** -0.068*** -0.019*** 0.037***
(No Control) (0.017) (0.010) (0.006) (0.005)
1(PE) -0.048*** -0.066*** -0.019*** 0.037***
(With Control) (0.016) (0.010) (0.006) (0.005)
Observations 283,767 283,767 283,767 283,767
Y-Mean 3.6 2.3 0.8 0.5
----------------------------------------------------------------------------------------------------------------
C: Log Financials
---------------------------------------------------------------------------
(1) (2) (3) (4)
Management Fee Building Lease Interest Expense Cash on Hand
----------------------------------------------------------------------------------------------------------------
1(PE) 0.074** 0.564*** 1.181*** -0.322***
(No Control) (0.032) (0.061) (0.096) (0.042)
1(PE) 0.074** 0.560*** 1.175*** -0.318***
(With Control) (0.032) (0.061) (0.096) (0.042)
Observations 231,556 231,584 231,613 231,569
Y-Mean 0.2 0.4 0.3 11.2
----------------------------------------------------------------------------------------------------------------
Note: This table presents estimates of the relationship between PE ownership and nursing home outcomes. Each
cell presents the coefficient b obtained by estimating equation 9 with a different outcome. The independent
variable is an indicator for whether a nursing home is PE-owned (=1 if PE-owned, 0 otherwise) starting in the
next year from the deal announcement date. Panel A presents results for quality outcomes as measured by Five-
star rating awarded by CMS - overall rating and deficiencies identified by independent contractors in audits,
respectively. A negative effect on ratings implies a decline in quality. Panel B presents results on per
patient nurse availability for all nurses, nurse assistants, licensed nurses, and registered nurses. Panel C
presents results on the log of management fees, building lease cost, interest expenses, and cash on hand. The
top row presents results with no controls. The bottom row presents the results including controls, which
consist of market-level and patient mix controls, as described in Section 6.1. All models include facility and
year fixed effects. All variables are winsorized at 1% and 99% levels. Standard errors are clustered by
facility.
Appendix: For Online Publication
A Data appendix
This paper uses three primary data sources. We use (1) publicly
available nursing home-level data, (2) patient-level administrative
claims data, both obtained from CMS, and (3) Pitchbook data on PE
deals. This section provides a detailed explanation of these data
sources and how we arrived at our analysis samples.
A.1 Nursing Home Data
Our data source on nursing home-level operations and performance is a
compilation of information obtained during annual surprise CMS
inspector audits and data on nursing home attributes and patient
characteristics reported by the facilities themselves.\33\ The data
span 2000 through 2017. In each year we observe about 15,000 unique
nursing homes, for a total of approximately 280,000 observations. Of
these, about 29,000 observations represent facilities acquired by PE
firms. The aggregate files provide annual data on basic facility
attributes, patient volume and case mix, nurse availability, and
various components of the Five Star ratings.\34\ These ratings started
in 2009, so we cannot observe ratings pre-buyout for deals before 2010.
Fortunately, half of the PE deals in our sample, accounting for 365
nursing homes, occurred post-2009.
---------------------------------------------------------------------------
\33\ These files were organized and made available for research by
the Long Term Care Focus research center at Brown University. See
www.ltcfocus.org for more details.
\34\ For more details on how the ratings are produced, see Rating
Guide.
Table 1 Panel A presents summary statistics on the Overall Five
Star rating as well as the other key nursing home-level variables used
in the analysis. We first present the mean and standard deviation for
the whole sample (columns 1-2), then divide observations into two
groups--for facilities that are not PE-owned (columns 4-5) and for
those that are (columns 6-7). We observe clear differences between PE-
owned facilities and those not owned (all statistically significant at
the 1% level except where noted). PE targets are slightly larger, have
fewer staff hours per resident, and a lower Overall Five Star rating.
There have been secular increases for the whole sector in both ratings
and staffing over time. For staffing, this reflects more stringent
standards from regulators over time. Average staff hours per patient
day increased from 3.5 in 2000 to 3.7 in 2017. Similarly, overall
average Five Star ratings increased from 2.9 in 2009 to 3.25 in 2017.
As the PE deals occurred primarily later in the sample, it is therefore
remarkable that they have lower measures of quality on average.
A.2 Patient Data
Our second data source consists of patient-level billing claims and
assessment data for Medicare fee-for-service beneficiaries from 2004 to
2016. We observe the universe of billing data for hospital care
(inpatient and outpatient) and nursing homes for these beneficiaries,
as well as detailed patient assessments recorded in the Minimum Data
Set (MDS).\35\ We use these files to track beneficiaries' demographics,
spending, and health outcomes such as mortality. The MDS helps observe
clinical assessments such as mobility and the use of antipsychotic
drugs.
---------------------------------------------------------------------------
\35\ Specifically, we use 100% samples of the following: Medicare
Beneficiary Summary File (MBSF), Hospital inpatient and outpatient, and
Skilled Nursing Facility claims files. These were obtained through a
reuse DUA with CMS and accessed through the NBER.
The unit of observation is a nursing home stay for a Medicare
beneficiary that begins during our sample period, which we begin in
2005 in order to have at least one look-back year. Our main sample
restriction is to identify index nursing home stays for patients,
defined as stays that begin at least a year after discharge from a
previous nursing home stay. This helps avoid mis-attributing adverse
effects to the wrong nursing home. To further avoid attribution error,
we consider only the patient's first index stay in our entire sample
period. Hence, each patient appears only once in our sample. Using this
approach, we settle on a sample of more than seven million patients
over 12 years. For each of these patients, we also observe clinical
assessments from the MDS, which we successfully match to the claims
files. Following the prior literature (Grabowski, Feng, Hirth, Rahman
and Mor, 2013), we use some other restrictions to arrive at our sample.
We restrict to patients over 65 years of age who are enrolled in
Medicare parts A and B for at least 12 months before the start of the
nursing home stay. This restriction ensures that we observe prior
medical care history and pre-existing conditions. We also restrict to
stays associated with a hospital visit in the previous month, so that
all patients are admitted after a hospital-based procedure and are
relatively homogeneous. We drop patients who went to a nursing home in
a state other than their state of residence as recorded in the Medicare
master beneficiary summary file. This drops a small fraction of
patients (less than 5%) and is meant to exclude patients who may be
traveling when admitted to a nursing home. We match the index nursing
home stays to the MDS sample on beneficiary ID, facility ID, and
admission date. We achieve a match rate of 94% and drop unmatched
patients. We drop facilities with fewer than 100 patients over the
---------------------------------------------------------------------------
entire sample period to avoid special facilities and mitigate noise.
Table 1 Panel B presents summary statistics on the final patient-
level sample. We use an indicator for death within 90 days following
discharge (including during the stay), based on death dates recorded in
the Medicare master beneficiary summary file. We use two measures of
spending. The first is the total amount that the nursing home bills to
Medicare and the patient for the index stay in 2016 dollars. Medicare
covers the entire cost until the 21st day of stay, at which point the
patient begins paying a coinsurance, which has risen somewhat over time
and is now $170.5 per day.\36\ In our data, about 90% of total payments
are by Medicare. PE-owned facilities charge about 10% more than other
facilities. The second measure is the total amount paid for the stay
and the 90 days following discharge. This captures any subsequent
hospital inpatient or outpatient care, and it provides a more holistic
picture of patient care.
---------------------------------------------------------------------------
\36\ See https://www.resdac.org/cms-data/files/ip-ffs/data-
documentation and https://www.
medicare.gov/Pubs/pdf/10153-Medicare-Skilled-Nursing-Facility-Care.pdf.
Demographic measures associated with risk are quite similar across
the types of facilities, including patient age, the share of patients
who are black and married, and the Charlson Comorbidity Index, a
standard measure of patient mortality risk based on co-morbidities
(Charlson, Szatrowski, Peterson and Gold, 1994).\37\ We create a high-
risk indicator that is one if the previous-quarter Charlson score is
greater than two. According to this definition, about 30% of patients
are high-risk. The difference between facility types is not
significant.
---------------------------------------------------------------------------
\37\ The ``Charlson score'' assigns a point score to each of 17
disease categories recorded during the 3 months before the index stay
and sums them to create an overall disease burden score.
Finally, we examine four measures of patient well-being which
comprise inputs to the quality portion of CMS' Five Star ratings. The
first is an indicator for the patient starting antipsychotic medication
during the stay. The second is an indicator for the patient's self-
reported mobility score declining during the stay. The third is an
indicator for developing a pressure ulcer. The fourth is an indicator
for the patient's self-reported pain intensity score increasing during
the stay.
A.3 PE Deal Data
Our primary source of data on PE transactions is a proprietary list
of deals in the ``Elder and disabled care'' sector compiled by
Pitchbook Inc., a leading market intelligence firm in this space. The
deals span 2004 to 2015. We match the target names to individual
nursing facilities using name (facility or corporate owner) and address
as recorded in CMS data.\38\ Target names in these deals typically
refer to holding companies, which often do not reflect the names of
individual facilities. The matching process required manual Internet
searches to confirm chain affiliations. We supplement the Pitchbook
data in two ways. First, we conduct additional Internet searches that
yielded a small number of PE deals not reported by Pitchbook. Second,
we obtain a list of merger and acquisition deals from 2005 to 2016 from
Levin Associates, a market intelligence firm that tracks the healthcare
sector. This helps us to identify facilities that did not experience a
new PE deal, but were acquired by an existing PE-owned chain.\39\
---------------------------------------------------------------------------
\38\ We obtain data on nursing home attributes (name, address,
city, owner name and type, number of beds) and quality measures
(deficiencies) from Nursing Home Compare. See https://
data.medicare.gov/data/nursing-home-compare for more details.
\39\ We matched approximately 290 additional facilities using
information from the Levin files to the CMS data. Of these, about 40
were PE-owned.
This process yielded 128 deals, which correspond to a change in
ownership to PE for 1,674 facilities. The deals are spread over time
(no particular year or part of the business cycle dominates) and across
PE firms. Figure B.1 shows the number of deals in each year. In total,
our data contain 136 unique PE firms that acquired nursing homes. Most
deals are syndicated and involve multiple PE firms. Table B.1 presents
the top 10 deals by number of facilities acquired. Deal sizes are
skewed, with the top 10 deals accounting for about 80% of all
facilities acquired. On average, we observe PE-owned facilities for
eight years post-acquisition.\40\
---------------------------------------------------------------------------
\40\ A likely source of measurement error is not capturing PE
disinvestment from facility ownership. For the top 10 deals (80% of
facilities) we verified PE exit via manual Internet searches and
incorporated it in the analysis. The main results are robust to
dropping observations of facilities that have been owned by PEs for 10
years or more. As expected, the coefficients modestly increase in
magnitude when we do so.
It is difficult to ascertain whether we comprehensively capture PE
activity in this sector. While there is no ``official'' tally of PE-
owned nursing homes to benchmark against, our sample size compares
favorably against an estimate of 1,876 nursing homes reportedly
acquired by PE firms over a similar duration, 1998-2008 (GAO, 2010).
Nonetheless, our analysis likely underestimates the extent of PE
activity in nursing homes, as matching between Pitchbook deals and
---------------------------------------------------------------------------
individual facilities is very challenging.
To understand whether deals are concentrated in particular regions,
we plot the location of PE-owned facilities across the U.S. in Figure
B.2. PE firms appear to be more active in large metropolitan markets,
and in certain states such as Florida, Texas, New York, Pennsylvania
and Massachusetts. However, there is no obvious concentration, and we
do not find systematic variation with local measures of income, age,
elder population, or share of patients eligible for Medicare Advantage.
A.4 Targeting
This paper does not address why nursing homes may or may not be
profitable acquisition targets, and does not assess returns from
investing. However, exploring what types of facilities are targeted can
help to interpret the effects of buyouts on patient welfare and is also
useful for identifying the most relevant control variables for our
empirical analysis. We describe which characteristics are robustly
associated with buyouts in Table A.1, which presents estimates of
Equation (11):
[GRAPHIC] [TIFF OMITTED] T1721.016
.epsHere, PEj,t is set to 100 if the facility j is acquired
in a PE deal in year t (we drop all years post-deal, and multiply by
100 for ease of reading). PEj,t is zero for never-PE and PE-
owned facilities before the deal. We include state and year fixed
effects.
We report models including variables known to be central to nursing
home quality of care and economics or that are potentially important
and robustly predict buyouts. In column 1, we find that facilities in
more urban counties are more likely to be targeted.\41\ Urban nursing
homes tend to be closer to hospitals and likely enjoy thicker labor
markets. Facilities in a state with a higher ratio of elderly people
are also more likely to be targeted. County-level income, race, and
home ownership do not predict buyouts. Results for these covariates are
not presented.
---------------------------------------------------------------------------
\41\ We define urban as being in the top 2 out of 9 county groups
classified as urban based on a Department of Housing and Urban
Development 2003 rural-urban classification.
In column 2, we turn to facility characteristics. Chains are more
likely to be acquired than independent facilities, likely reflecting
substantial fixed costs in deal-making. Hospital-owned facilities are
less likely to be targeted. PE firms also tend to target larger and
higher-occupancy facilities. We consider patient-level characteristics
in column 3: the share of the nursing home's patients covered by
Medicaid, the share on private insurance, and the share who are Black.
The first two are strongly negatively associated with buyouts, meaning
that a higher share of Medicare patients (the omitted group) is
positively associated with being targeted. In column 4, we assess two
facility-level quality measures we employ in the analysis: Five Star
overall rating and staff hours per patient day. Both are negatively
associated with buyouts, but once we control for rating, staffing is
not significant. These results indicate that PE firms target relatively
---------------------------------------------------------------------------
low-performing nursing homes.
Finally, in column 5 we include simultaneously all of the variables
from the previous models that had predictive power. Some, such as
admits per bed and hospital ownership, become small and insignificant
after controlling for the other variables. Notably, the state elder
ratio, chain indicator, and Five star rating retain their magnitudes
and precision.
Table A.1: Targeting
----------------------------------------------------------------------------------------------------------------
Mean (1) (2) (3) (4) (5)
----------------------------------------------------------------------------------------------------------------
Urban Indicator 0.56 0.193*** 0.105**
(0.037) (0.041)
State Elder Ratio 0.24 4.340*** 18.819***
(1.328) (3.906)
1(Chain) 0.53 0.835*** 0.367***
(0.033) (0.029)
Hospital-Owned 0.07 -0.221*** -0.003
(0.053) (0.067)
Log (Beds) 4.5 0.287*** 0.086***
(0.030) (0.032)
Admits Per Bed 2.08 0.051*** 0.009
(0.007) (0.015)
Ratio Medicaid 0.60 -0.879*** -0.434*
(0.117) (0.229)
Ratio Private 0.25 -1.441*** -0.422*
(0.144) (0.236)
Ratio Black 0.10 0.002
(0.099)
Overall Rating 3.15 -0.075*** -0.066***
(0.015) (0.015)
Staff Hr per Patient Day 3.55 -0.022
(0.018)
Observations 235,670 218,592 218,592 103,831 103,831
Y-Mean (pp) 0.6 0.6 0.6 0.6 0.6
----------------------------------------------------------------------------------------------------------------
Note: This table shows estimates of the relationship between pre-existing nursing home characteristics and
whether a nursing home is a target of a PE buyout. Column 1 presents market-level attributes: an indicator for
urban and the share of state population which is elderly. Column 2 presents facility-level attributes:
indicator for being member of a chain, indicator for the nursing home being hospital-based, the log number of
beds, and admits per bed. Column 3 presents patient mix controls: share of patients covered by Medicaid, share
of patients who pay privately, and the share of patients who are black. Column 4 presents quality metrics such
as Five-star ratings awarded by CMS and staff hours per patient day. We re-run the regression on all variables
which appear significant in Columns 1 to 4 in Column 5. The dependent variable is 100 if the nursing home was
acquired by PE in that year and 0 otherwise. We remove all observations of private equity-owned facilities in
years following the take-over by PE. We control for state and year FEs. Standard errors are clustered by
facility.
B Supplementary Figures and Tables
[GRAPHIC] [TIFF OMITTED] T1721.017
.eps Note: This figure presents the number of unique deals for
active nursing homes by PE firms for each year over the period 2004-
2015.
[GRAPHIC] [TIFF OMITTED] T1721.018
.eps Note: This figure presents the number of facilities bought by
PE firms in each county over the period 2004-2015. We identified 1,674
such facilities.
[GRAPHIC] [TIFF OMITTED] T1721.019
.eps Note: This figure presents event studies on initial patient
assessments around the time a nursing home experiences a PE buyout. To
match the event study plots presented in the main text, we estimate
these models on collapsed facility-year level data and use the same
specification, i.e., facility and year fixed effects, patient mix, and
market controls, as described in Section 6.1. Each point in the figures
represents the coefficient bs obtained by estimating
Equation (10) as discussed in Section 6. Year = -2 is the omitted
point. Panel A presents results on the share of patients diagnosed with
Dementia, Panel B on Alzheimers, Panel C on Hip Fractures, and Panel D
on Urinary Tract Infections, respectively, at admission to the index
nursing home stay. Standard errors are clustered by facility.
[GRAPHIC] [TIFF OMITTED] T1721.020
.eps Note: This figure provides descriptes on patient zip code
distance to index nursing home zip code. Panels A and B present CDFs of
the distance from patient zip code to index nursing home zip code.
Panel A presents the CDF pooling PE and non-PE patients together. It
also identifies the median, 75th and 90th percentile values. Panel B
presents the CDFs separately for PE and non-PE patients, and their
respective median values. Panel C presents the annual trendline for the
share of patients going to their closest nursing home. Panel D presents
the event study of the mean patient distance around a PE acquisition.
Each point in the figure represents the coefficient bs
obtained by estimating Equation (10) as discussed in Section 6. Year =
-2 is the omitted point. The model includes facility and HRR year
fixed effects, patient mix, and market controls. Standard errors are
clustered by facility.
[GRAPHIC] [TIFF OMITTED] T1721.021
.eps Note: This figure presents event studies on patient outcome
measures around the time a nursing home experiences a PE buyout. To
match the event study plots presented in the main text, we estimate
these models on collapsed facility-year level data and use the same
specification, i.e., facility and year fixed effects, patient mix, and
market controls, as described in Section 6.1. Each point in the figures
represents the coefficient bs obtained by estimating
Equation (10) as discussed in Section 6. Year = -2 is the omitted
point. Panels A and B present results on the share of patients dying
within 90 days of discharge from the index stay, and total amount
billed over the 90-day episode including the index stay (2016$). Panels
C to F present results for MDS assessment based outcomes--the facility
level mean for indicators for patient starting antipyschotics, decrease
in patient mobility, developing/worsening pressure ulcers, and increase
in pain intensity respectively. Spending is winsorized at the 1% and
99% level. Standard errors are clustered by facility.
[GRAPHIC] [TIFF OMITTED] T1721.022
.eps Note: This figure presents additional plots pertaining to
Marginal Treatment Effects (MTE) analysis using the Medicare patient-
level data. Panel A presents the overlap in distributions of PE and
non-PE groups by propensity score, using a linear scale for the Y-axis.
Panel B demonstrates robustness of the slope of the MTE curve to using
different orders of polynomials. Section 5.2.2 presents details of the
MTE estimation.
[GRAPHIC] [TIFF OMITTED] T1721.023
.eps Note: This figure presents scatter plots of changes in total
staff hours available per patient day in the three years post-PE buyout
versus three years pre-buyout on the X-axis, against changes in CMS
Five-star rating over the same period on the Y-axis. Panel A presents
overall rating, and Panel B presents survey based deficiency ratings.
The data was collapsed into 20 equal sized bins and we plot the means
in each bin. The figures also present fitted lines for these plots
obtained using linear regressions on the underlying data. Each plot
also presents the slope coefficient with standard error.
[GRAPHIC] [TIFF OMITTED] T1721.024
.eps Note: This figure presents event studies on facility
characteristics around the time a nursing home experiences a PE buyout.
Each point in the figures represents the coefficient bs
obtained by estimating Equation (10) as discussed in Section 6. Year =
-2 is the omitted point. Panels A and B present results on the log of
beds and admissions at the facility level, and Panel C on log
admissions at the market level (HRR). All models--except when studying
market-level volume--include facility and year fixed effects, patient
mix, and market controls, as described in Section 6.1. All dependent
variables are winsorized at 1% and 99% levels. Standard errors are
clustered by facility.
Table B.1: Top 10 Private Equity Deals
------------------------------------------------------------------------
Sr. Private Equity Number of
No. Target Name Firm(s) Deal Year Facilities
------------------------------------------------------------------------
1 Genesis Formation Capital, 2007-15 327
Healthcare JER Partners
2 Golden Living Fillmore Capital 2006 321
Partners
3 Kindred Signature Healthcare, 2014 150
Healthcare Hillview Capital
4 HCR Manorcare Stockwell Capital, 2007-18 145
The Carlyle Group
5 Mariner Fillmore Capital 2004 95
Healthcare Partners
6 Skilled Onex, Heritage 2005-07 76
Healthcare Partners
Group
7 Trilogy Lydian Capital 2007-15 65
Investors Partners
8 Lavie Care Formation Capital, 2011 61
Centers Senior Care
Development
9 Laurel Health Formation Capital, 2006-16 41
Care Company Longwing Real Estate
Ventures
10 Harden NXT Capital, Oaktree 2013 35
Healthcare Speciality Lending
------------------------------------------------------------------------
Note: This table presents some details on the top 10 PE deals in our
sample, ordered by the number of unique nursing home facilities
involved in the deal. This represents the number of facilities we were
able to identify and match in our administrative data, the actual
number of facilities in the deal may have been different. We set the
PE indicator to turn on in the year following the deal year. If a
closing year is mentioned, it implies the PE investors exited or went
public in that year. Accordingly, we turn off the PE indicator in the
closing year.
Table B.2: Complier Characteristics
----------------------------------------------------------------------------------------------------------------
Observations Coefficient (Std. Errors) Ratio
----------------------------------------------------------------------------------------------------------------
Full Sample 7,365,934 -0.0445*** (0.003)
A. Age and Risk
Low Risk, 65-80 2,052,655 -0.0405*** (0.002) 0.91
High Risk, 65-80 881,854 -0.0471*** (0.003) 1.06
Low Risk, 80+ 3,326,940 -0.0451*** (0.003) 1.01
High Risk, 80+ 1,104,387 -0.0478*** (0.003) 1.07
B. Gender
Male 2,640,611 -0.0456*** (0.003) 1.02
Female 4,725,295 -0.0439*** (0.003) 0.99
C. Marital Status
Unmarried 4,838,365 -0.0446*** (0.003) 1.00
Married 2,527,548 -0.0439*** (0.003) 0.99
D. Beneficiary Zip Income
Income < Median 3,681,687 -0.0554*** (0.004) 1.24
Income > Median 3,684,035 -0.0353*** (0.003) 0.79
E. Race
White 6,483,451 -0.0451*** (0.003) 1.01
Other 881,923 -0.0380*** (0.003) 0.85
----------------------------------------------------------------------------------------------------------------
Note: This table presents first stage equivalent estimates of the 2SLS for various patient subsamples. We
present the coefficient b, obtained by estimating the equation PEi = aj + am,t + b 1(DDi > Median) + ei. 1(DDi
> Median) is an indicator for patient i's differential distance to the nearest PE-owned facility being greater
than the median value. The model includes facility j and patient HRR year fixed effects, but no other
controls. We divide the sample by age and risk, gender, marital status, income in patient zip code, and race.
Details are available in Section 4.2. We also present the ratio of the coefficient obtained for each subsample
to that for the full sample. Standard errors are clustered by facilities.
Table B.3: Mortality Effects by Duration
----------------------------------------------------------------------------------------------------------------
(1) (Stay + 30 (2) (Stay + 60 (3) (Stay + 90 (4) (Stay + 365
Days) Days) Days) Days)
----------------------------------------------------------------------------------------------------------------
1(PE) 0.009 0.0148** 0.0169** 0.0239***
(0.006) (0.007) (0.007) (0.008)
Observations 7,365,934 7,365,934 7,365,934 7,365,934
Y-Mean 0.12 0.15 0.17 0.24
F-Stat 223.9 223.9 223.9 223.9
Coefficient/PY-Mean 8% 10% 10% 10%
----------------------------------------------------------------------------------------------------------------
Note: This table presents estimates of the relationship between PE ownership and patient mortality. Each cell
presents the coefficient b obtained by estimating Equation (2) by 2SLS. The independent variable is an
indicator for the patient being admitted to a PE nursing home, instrumented by differences in distance to the
nearest PE and non-PE facility. We present effects for mortality at different durations--patient death within
30, 60, 90, and 365 days of discharge from the index stay. All regressions include facility and patient HRR
year fixed effects, and patient risk controls. Patient risk controls include age, race, gender, marital
status, indicators for 17 pre-existing conditions used to compute the Charlson Index, and an indicator for
dual eligibility. Standard errors are clustered by facility.
Table B.4: Mortality Costs
------------------------------------------------------------------------
(1) Male (2) Female
------------------------------------------------------------------------
A: IV estimates
1(PE) 0.0105 0.0210**
(0.012) (0.008)
Observations 2,640,611 4,725,295
Y-Mean 0.21 0.14
F-Stat 221 221
------------------------------------------------------------------------
B: Placebo
1(PE) 0.0091 0.0044
(0.006) (0.005)
Observations 2,497,830 4,661,700
Y-Mean 0.23 0.15
F-Stat 431 440
------------------------------------------------------------------------
C: Calculations
Number of Patients in PE Facilities 435,035 741,838
Additional Deaths 4,568 15,579
------------------------------------------------------------------------
Total Lives Lost 20,146
Mean Life Expectancy 6.7 8.2
Additional Loss in Person Years 30,814 128,384
------------------------------------------------------------------------
Total Person Years Lost 159,198
Value of Life Year (2016$) 130,000
Total Cost (2016$) 20.7 Billion
------------------------------------------------------------------------
Note: This table presents estimates of additional deaths, life-years
lost, and the associated cost using standard estimates of statistical
value of a life-year due to PE ownership of nursing homes. Panel A
presents the coefficient b obtained by estimating Equation (2) by
2SLS. The independent variable is the indicator for a patient being
admitted to a PE nursing home, instrumented by differences in distance
to the nearest non-PE and PE nursing home. The outcome variable is an
indicator for patient death within 90 days of discharge from the index
stay. Panel B presents a placebo analysis for this patient subsample
using the same approach as for the whole sample, as presented in Table
4. All models include facility and patient HRR - year fixed effects
and the usual patient risk controls as in the main specification.
Standard errors are clustered by facility. Panel C presents
calculations to estimate lives, life-years lost and total cost based
on Panel A coefficients. We calculate average life expectancy at
discharge (by gender) using the observed distribution of lifespans for
Medicare patients. For patients still alive at the end of our sample,
we assign a year of death based on patient gender and age using Social
Security actuary tables. We adjust downward the resulting life
expectancy to account for the fact the decedents tend to be older than
the average nursing home patient (about two years).
Table B.5: Patient-Level Analysis: OLS Results
----------------------------------------------------------------------------------------------------------------
A: Initial Patient Assesments
----------------------------------------------------------------------------------------------------------------
(1) (2) (3) (4)
Dementia Alzheimers Hip Fracture Urinary Tract
at Admission at Admission at Admission Infection
at Admission
----------------------------------------------------------------------------------------------------------------
1(PE) -0.0098*** -0.0040*** -0.0034*** 0.0044**
(0.002) (0.001) (0.001) (0.002)
Observations 7,365,934 7,365,934 7,365,934 7,365,934
Y-Mean 0.16 0.05 0.09 0.16
----------------------------------------------------------------------------------------------------------------
B: Main Outcomes
----------------------------------------------------------------------------------------------------------------
(1) (2) (3)
Mortality Log Amount Billed Log Amount Billed
(Stay + 90 Days) Per Per
Patient Stay Patient Stay + 90
Days
----------------------------------------------------------------------------------------------------------------
1(PE) 0.0034*** -0.0221*** -0.0118**
(0.001) (0.006) (0.005)
Observations 7,365,934 7,365,934 7,365,934
Y-Mean 0.17 9.07 9.57
----------------------------------------------------------------------------------------------------------------
C: Assesment Based Outcomes
----------------------------------------------------------------------------------------------------------------
(1) (2) (3) (4)
1(Starts Anti- 1(Mobility 1(Develops 1(Pain Intensity
Psychotics) Decreases) Ulcers) Increases)
----------------------------------------------------------------------------------------------------------------
1(PE) 0.0115*** 0.0349*** 0.0094*** 0.0266***
(0.001) (0.003) (0.003) (0.005)
Observations 7,365,934 7,365,934 7,365,934 7,365,934
Y-Mean 0.06 0.53 0.09 0.27
----------------------------------------------------------------------------------------------------------------
Note: This table presents OLS estimates of the relationship between PE ownership and patient health and
spending. Each cell presents the coefficient b obtained by estimating Equation (2) by OLS. The independent
variable is an indicator for the patient being admitted to a PE nursing home. In Panel A, we present effects
for initial patient assessments--dementia, alzheimers, hip fracture and urinary tract infection at time of
admission. In Panel B, we present effects on patient death within 90 days of discharge from the index stay and
total amount billed during the stay and during the 90 day episode (2016$). Panel C presents results for
assessment based outcomes recorded in the MDS--an indicator for patient starting antipyschotics, decrease in
patient mobility, developing/worsening pressure ulcers, and increase in pain intensity. All regressions
include facility and patient HRR x Year fixed effects, and patient risk controls. Patient risk controls
include age, race, gender, marital status, indicators for 17 pre-existing conditions used to compute the
Charlson Index, and an indicator for dual eligibility. Standard errors are clustered by facility.
Table B.6: Robustness: Facility-Level Outcomes
----------------------------------------------------------------------------------------------------------------
A: Five Star Rating
-----------------------------------------------------------------------
(1) (2)
Deficiency Overall
Rating Rating
----------------------------------------------------------------------------------------------------------------
1. Chain Controls
1(PE) -0.074** -0.079**
(0.036) (0.028)
2. W/O Top 2 Deals
1(PE) -0.145*** -0.204***
(0.050) (0.042)
3. Only For Profit
1(PE) -0.077** -0.082**
(0.036) (0.028)
Observations 138,051 138,051
Y-Mean 2.9 3.2
----------------------------------------------------------------------------------------------------------------
B: Staff Per Patient Day
-----------------------------------------------------------------------
(1) (2) (3) (4)
All Staff Nurse Assistant Licensed Nurse Registered Nurse
----------------------------------------------------------------------------------------------------------------
1. Chain Controls
1(PE) -0.050*** -0.068*** -0.019*** 0.037***
(0.016) (0.010) (0.006) (0.005)
2. W/O Top 2 Deals
1(PE) -0.100*** -0.101*** -0.021** 0.030***
(0.026) (0.015) (0.009) (0.008)
3. Only For Profit
1(PE) -0.045*** -0.062*** -0.024*** 0.039***
(0.017) (0.010) (0.006) (0.005)
Observations 283,767 283,767 283,767 283,767
Y-Mean 3.6 2.3 0.8 0.5
----------------------------------------------------------------------------------------------------------------
C: Log Financials
-----------------------------------------------------------------------
(1) (2) (3) (4)
Management Fee Building Lease Interest Expense Cash on Hand
----------------------------------------------------------------------------------------------------------------
1. Chain Controls
1(PE) 0.074** 0.564*** 1.181*** -0.321***
(0.032) (0.061) (0.096) (0.042)
2. W/O Top 2 Deals
1(PE) 0.042 0.809*** 2.048*** -0.366***
(0.050) (0.102) (0.160) (0.068)
3. Only For Profit
1(PE) 0.056* 0.570*** 1.179*** -0.289***
(0.032) (0.061) (0.096) (0.043)
Observations 231,556 231,584 231,613 231,569
Y-Mean 0.2 0.4 0.3 11.2
----------------------------------------------------------------------------------------------------------------
Note: This table presents robustness tests on the estimates of the relationship between PE buyouts and Five star
ratings, nurse availability, and financials. The corresponding main results are presented Table 8. Each cell
presents the coefficient b obtained by estimating Equation (9) with a different outcome. The independent
variable is an indicator for whether a nursing home is PE-owned (=1 if PE-owned, 0 otherwise) starting in the
next year from the deal announcement date. We control for a chain indicator in the first row, remove the top 2
deals by size in the second row, and estimate the results on a sample limited to for-profit facilities in the
third row. We do not present results limiting to the Top 5 deals as Five Star ratings are only available post-
2009, and 4 Top 5 deals occurred before 2009. All models include facility and year fixed effects. All
variables are winsorized at 1% and 99% levels. Standard errors are clustered by facility.
Table B.7: Patient Volume
------------------------------------------------------------------------
Facility Level Market Level
--------------------------------------------------
(2) Log (3) Log
(1) Log Beds Admissions Admissions
------------------------------------------------------------------------
1(PE) -0.002 0.036*** 0.014
(No Control) (0.003) (0.009) (0.014)
1(PE) -0.003 0.035*** 0.007
(With Control) (0.003) (0.009) (0.011)
Observations 283,767 283,767 5,364
Y-Mean 4.5 4.8 12.7
------------------------------------------------------------------------
Note: This table presents estimates of the relationship between PE
ownership and patient volume. Each cell presents the coefficient b
obtained by estimating Equation (9) with a different outcome. The
independent variable is an indicator for whether a nursing home is PE-
owned (=1 if PE-owned, 0 otherwise) starting in the next year from the
deal announcement date. We present results on the log number of beds,
log number of admissions in facility, and log number of admissions at
HRR level. The bottom row presents the results including controls,
which consist of market-level and patient mix controls, as described
in Section 6.1. All models include facility and year fixed effects.
All variables are winsorized at 1% and 99% levels. Standard errors are
clustered by facility.
______
Congress of the United States
Washington, DC 20510
November 15,2019
Kewsong Lee
Co-Chief Executive Officer
The Carlyle Group
1001 Pennsylvania Avenue, NW
Washington, DC 20004-2505
Glenn A. Youngkin
Co-Chief Executive Officer
The Carlyle Group
1001 Pennsylvania Avenue, NW
Washington, DC 20004-2505
Dear Messrs. Lee and Yonugkin:
We are writing to request information regarding the Carlyle Group's
(Carlyle) investment in companies providing nursing home care and other
long-term care services and to request information about your firm's
structure and finances as it relates to these companies.
Private equity funds often operate under a model where they purchase
controlling interests in companies for a short time, load them up with
debt, strip them of their assets, extract exorbitant fees, and sell
them at a profit--implementing drastic cost-cutting measures at the
expense of consumers, workers, communities, and taxpayers. For that
reason, we have concerns about the rapid spread and effect of private
equity investment in many sectors of the economy, especially industries
that affect vulnerable populations and rely primarily on taxpayer-
funded programs such as Medicare and Medicaid, like the nursing home
industry. We are particularly concerned about your firm's investment in
large for-profit nursing home chains, which research has shown often
provide worse care than not-for-profit faci1ities.\1\ In light of these
concerns, we request information about your firm, the portfolio
companies in which it has invested, and the performance of those
investments.
---------------------------------------------------------------------------
\1\ International Journal of Health Services, ``Ownership,
Financing, and Management Strategies of the 10 largest for-profit
nursing home chains in the United States,'' Charlene Harrington et al.,
2011, https://www.ncbi.nlm.nih.gov/pubmed/22053531; Kaiser Family
Foundation, ``Reading the Stars: Nursing Home Quality Star Ratings,
Nationally and by State,'' May 2015, http://files.kff.org/attachment/
issue-brief-reading-the-stars-nursing-home-quality-star-ratings-
nationally-and-by-state.
Nursing homes provide a wide range of important medical and personal
care services to a growing and vulnerable elderly population, with 1.3
million residents in the United States currently receiving care in more
than 15,000 facilities.\2\ For decades, reports and data have
highlighted the shocking living conditions found in many nursing home
and other long-term care facilities across the country.\3\ Twelve years
ago, for example, journalists uncovered how a group of private
investment firms acquired 49 nursing homes, including a facility in
Florida where managers slashed the number of registered nurses by half
and cut supply and activity budgets. Residents, meanwhile, suffered
from preventable infections and injuries.\4\ Last year, news reports
similarly detailed how a for-profit nursing home employed drastic cost
cutting measures, ``exposed its roughly 25,000 patients to increasing
health risk,' and ultimately filed for bankruptcy--all after a private
equity firm acquired the company.\5\
---------------------------------------------------------------------------
\2\ National Center for Health Statistics, ``Long-term Care
Providers and Services Users in the United States, 2015-2016,''
February 2019, https://www.cdc.gov/nchs/data/series/sr_03/sr03_43-
508.pdf.
\3\ New York Times, ``At Many Homes, More Profit and Less
Nursing,'' Charles Duhigg, September 23, 2017, https://www.nytimes.com/
2007/09/23/business/23nursing.html; Reveal, ``The rats sensed she was
going to pass away,'' Jennifer Gollan, September 18, 2019, https://
www.revealnews.org/article/elderly-often-face-neglect-in-california-
care-homes-that-exploit-workers/.
\4\ New York Times, ``At Many Homes, More Profit and Less
Nursing,'' Charles Duhigg, September 23, 2017, https://www.nytimes.com/
2007/09/23/business/23nursing.html.
\5\ Washington Post, ``Overdoses, bedsores, broken bones: What
happened when a private-equity firm sought to care for society's most
vulnerable,'' Peter Whoriskey and Dan Keating, November 25, 2018,
https://www.washingtonpost.com/business/economy/opioid-overdoses-
bedsores-and-broken-bones-what-happened-when-a-private-equity-firm-
sought-profits-in-caring-for-societys-most
-vulnerable/2018/11/25/09089a4a-ed14-11e8-baac-2a674e91502b_story.html.
This is particularly concerning given the fact that two-thirds of
nursing home residents rely on government-sponsored health insurance
coverage, meaning both not-for-profit and for-profit nursing homes
benefit from government funding.\6\ Medicaid is the primary payer \7\
for nursing home care, with Medicare and Medicaid combined covering
approximately 75 percent of nursing home residents.\8\ In 2015,
taxpayers sent more than $55 billion to the nursing home industry to
cover the costs of long-term care. These reports and corresponding
research raise serious questions about the role of private equity firms
in the nursing home care industry, and the extent to which these firms'
emphasis on profits and short-term return is responsible for declines
in quality of care. They also raise concerns over the stewardship of
taxpayer dollars, when--in many cases--these facilities continue to
receive Medicare and Medicaid funding despite their decline in quality.
---------------------------------------------------------------------------
\6\ Kaiser Family Foundation, ``Distribution of Certified Nursing
Facility Residents by Primary Payer Source,'' accessed on Nov. 14,
2019, https://www.kff.org/other/state-indicator/distribution-of-
certified-nursing-facilities-by-primary-payer-source/
?currentTimeframe=O&sortModel=%7
B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.
\7\ Kaiser Family Foundation, ``Medicaid's Role in Nursing Home
Care,'' June 20, 2017, https://www.kff.org/infographic/medicaids-role-
in-nursing-home-care/.
\8\ Kaiser Family Foundation, ``Distribution of Certified Nursing
Facility Residents by Primary Payer Source,'' accessed on Nov. 14,
2019, https://www.kff.org/other/state-indicator/distribution-of-
certified-nursing-facilities-by-primary-payer-source/
?currentTimeframe=O&sortModel=%7
B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.
The majority of nursing facilities--almost 70%--are for-profit, and
over half are chain-affiliated.\9\ The overwhelming majority of
research conducted over the last 2 decades shows that for-profit and
chain affiliated \10\ companies provide a lower quality of care and
experience more serious health and safety deficiencies when compared to
non-profit facilities.\11\
---------------------------------------------------------------------------
\9\ National Center for Health Statistics, ``Long-term Care
Providers and Services Users in the United States, 2015-2016,''
February 2019, https://www.cdc.gov/nchs/data/series/sr_03/sr03_43-
508.pdf.
\10\ Facilities owned or leased by ``an organization that owns two
or more long-term care facilities.''
\11\ International Journal of Health Services, ``Ownership,
Financing, and Management Strategies of the 10 largest for-profit
nursing home chains in the United States,'' Charlene Harrington et al.,
2011; Medical Care Research and Review, ``Nursing home profit status
and quality of care: Is there any evidence of an association?'',
Michael P. Hillmer et al., April 2005, https://www.ncbi.nlm.nih.gov/
pubmed/15750174.
Additionally, for-profit facilities receive the lowest scores in the
Centers for Medicare and Medicaid Services' (CMS) nursing home rating
system that takes into account, state health inspections, staffing
ratios and quality measures.\12\
---------------------------------------------------------------------------
\12\ Kaiser Family Foundation, ``Reading the Stars: Nursing Home
Quality Star Ratings, Nationally and by State,'' May 2015, http://
files.kff.org/attachment/issue-brief-reading-the-stars-nursing-home-
quality-star-ratings-nationally-and-by-state.
Private equity investment appears to exacerbate the problems faced at
chain-
affiliated for-profit nursing homes. Studies show that private equity-
owned facilities generally ``deliver poorer quality of care'' than
other chain-affiliated for-profit facilities; are likely to try to
reduce cost by ``substituting expensive but skilled RNs with cheaper
and less skilled nurses;'' and ``report significantly higher number of
deficiencies'' that climb with more years of private equity ownership.
As a result, private equity-owned nursing homes have 21% higher
deficiencies, 25% lower nursing staff skill mix, and ``worse results on
pressure sore prevention . . . and [higher] pressure ulcer [] risk
prevalence.''\13\ That was reportedly the case at HCR ManorCare--the
second largest for-profit nursing home chain in the United States. In
the years following its acquisition by your firm, ``the number of
citations increased for, among other things, neither preventing nor
treating bed sores; medication errors; not providing proper care for
people who need special services such as injections, colostomies and
prostheses; and not assisting patients with eating and personal
hygiene.''\14\
---------------------------------------------------------------------------
\13\ Journal of Health Care Finance, ``Private Equity Ownership of
Nursing Homes: Implications for Quality,'' Rohit Pradhan et al., June-
July 2014, http://healthfinancejournal.com/index.php/johcf/article/
view/12.
\14\ Washington Post, ``Overdoses, bedsores, broken bones: What
happened when a private-
equity firm sought to care for society's most vulnerable,'' Peter
Whoriskey and Dan Keating, November 25, 2018, https://
www.washingtonpost.com/business/economy/opioid-overdoses-bedsores-and-
broken-bones-what-happened-when-a-private-equity-firm-sought-profits-
in-caring-for-societys-most-vulnerable/2018/11/25/09089a4a-ed14-11e8-
baac-2a674e91502b_story.html.
Moreover, while the quality of service declines, the complicated
ownership and operating structure of these investments ``limit legal
remedies available to aggrieved residents.''\15\ For example, after a
resident died at the private-equity-owned Habana Health Care Center (as
a result of ``a wound [that] should have been detected much earlier''),
a family member tried to sue the owners of the facility, only to
discover that the facility's complicated ownership structure ``meant
that even if she prevailed in court, the investors' wallets would
likely be out of reach.''\16\ Shifting funds to other affiliated
entities, or to the private equity firm itself, to immunize itself from
liability for judgments against a target company is a widespread
practice in the private equity industry.
---------------------------------------------------------------------------
\15\ Journal of Health Care Finance, ``Private Equity Ownership of
Nursing Homes: Implications for Quality,'' Rohit Pradhan et al., June-
July 2014, http://healthfinancejournal.com/index.php/johcf/article/
view/12.
\16\ New York Times, ``At Many Homes, More Profit and Less
Nursing,'' Charles Duhigg, September 23, 2007, https://www.nytimes.com/
2007/09/23/business/23nursing.html.
Private equity investment in this sector has increased over the last
few decades. The Government Accountability Office found that over the
span of 10 years ending in 2008, private investment firms acquired
approximately 1,900 unique nursing homes.\17\ Today, private equity
firms own or operate several large for-profit chains that control
hundreds of facilities and provide nursing home care among other long-
term care services.\18\ Carlyle reportedly owns or has had investments
in companies providing nursing home care. In order to help us
understand your firm' s role in the nursing home sector, we ask that
you provide answers to the following questions no later than November
29, 2019.
---------------------------------------------------------------------------
\17\ Government Accountability Office, ``Nursing Homes: Complexity
of Private Investment Purchases Demonstrates Need for CMS to Improve
the Usability and Completeness of Ownership Data,'' September 2010,
https://www.gao.gov/assets/320/310562.pdf.
\18\ IQVIA, ``U.S. Elder Care Market Summary,'' September 2019,
https://www.skainfo.com/reports/u.s.-elder-care-market-summary.
1. Please provide the disclosure documents and information
enumerated in Sections 501 and 503 of the Stop Wall Street Looting
Act.\19\
---------------------------------------------------------------------------
\19\ Stop Wall Street Looting Act, S. 2155, https://
www.congress.gov/bill/116th-congress/senate-bill/2155.
2. Which nursing home or other long-term care service companies,
including all affiliates or related entities, does Carlyle have a stake
in or own? Please provide the name of and a brief description of the
services each company provides--including the number of facilities that
---------------------------------------------------------------------------
it owns or operates.
a. Which nursing home or other long-term care companies,
including all affiliates or related entities, has Carlyle had a stake
in or owned in the past 20 years? Please provide the name of and a
brief description of the services each company provides or provided--
including the number of nursing home and other long-term care
facilities that it owned or operated.
b. For each nursing home or other long-term care service
company Carlyle had a stake in or owned in the past 20 years, including
all affiliates or related entities, please provide the following
information for each year that the firm have had a stake in or owned
this company and the 5 years preceding the firm's investment.
i. The name of the company
ii. Total number of facilities, by type of facility
iii. Ownership stake
iv. Total revenue, and the total revenue from Medicare, and
from Medicaid
v. Total transaction, advisory, or other fees collected
after the acquisition of the company
vi. Net income
vii. Total number of employees for each facility
viii. Total number of patients for each facility, and the
total number whose care is paid for by Medicare, and by Medicaid
ix. Other private-equity firms that own a stake in the
company
3. Private-equity firms reportedly employ sale-leaseback
arrangements in order to quickly recover investments. For each company
listed in questions 2(a) and 2(b), please list the number of nursing
home or other long-term care facilities for which you acquired real
estate assets, and whether a sale-leaseback agreement has been executed
for any of those companies or facilities.
4. Has any nursing home or other long-term care company,
including all affiliates or related entities, in which Carlyle has an
ownership stake or has had an ownership stake in the last 20 years
received Section 232 Department of Housing and Urban Development (HUD)-
insured mortgages? If so, please provide the name of each facility and
the total value of each loan insured by HUD.
5. Has any nursing home or other long-term care company,
including all affiliates or related entities, in which Carlyle has an
ownership stake or has had an ownership stake in the last 20 years,
been placed in receivership? Please provide the name of each facility.
6. Has any nursing home or other long-term care company,
including all affiliates or related entities, in which Carlyle has an
ownership stake or has had an ownership stake in the last 20 years,
been found to have violated any federal or state laws or regulations?
If so, please provide a complete list, including the date and
description, of all such violations. Please also include a list of all
deficiencies identified in state or federal surveys of the facilities
owned by the company for each year.
7. Has any nursing home or other long-term care company,
including all affiliates or related entities, in which Carlyle has an
ownership stake or has had an ownership stake in the last 20 years,
reached a settlement with any federal or state law enforcement entity
related to a potential violation of any federal or state laws or
regulations or deficiencies in providing care? If so, please provide a
complete list, including the date and description, of all such
settlements.
8. Has any nursing home or other long-term care company,
including all affiliates or related entities, in which Carlyle has an
ownership stake or has had an ownership stake in the past 20 years,
reached a settlement with any individual who was provided services by
the company related to a potential violation of any federal or state
laws or regulations or deficiencies in providing care? If so, please
provide a complete list, including the date and description, of all
such settlements.
Thank you for your attention to this matter.
Sincerely,
Elizabeth Warren Mark Pocan
United States Senator Member of Congress
Sherrod Brown
United States Senator
______
Congress of the United States
Washington, DC 20510
November 15, 2019
Arnold Whitman
Chairman
Formation Capital
3500 Lenox Road, Suite 510
Atlanta, Georgia 30326
Brian Beckwith
Formation Capital
3500 Lenox Road, Suite 510
Atlanta, Georgia 30326
Dear Messrs. Whitman and Beckwith:
We are writing to request information regarding Formation Capital's
(Formation) investment in companies providing nursing home care and
other long-term care services and to request information about your
firm' s structure and finances as it relates to these companies.
Private equity funds often operate under a model where they purchase
controlling interests in companies for a short time, load them up with
debt, strip them of their assets, extract exorbitant fees, and sell
them at a profit--implementing drastic cost-cutting measures at the
expense of consumers, workers, communities, and taxpayers. For that
reason, we have concerns about the rapid spread and effect of private
equity investment in many sectors of the economy, especially industries
that affect vulnerable populations and rely primarily on taxpayer-
funded programs such as Medicare and Medicaid, like the nursing home
industry. We are particularly concerned about your firm's investment in
large for-profit nursing home chains, which research has shown often
provide worse care than not-for-profit facilities.\1\ In light of these
concerns, we request information about your firm, the portfolio
companies in which it has invested, and the performance of those
investments.
---------------------------------------------------------------------------
\1\ International Journal of Health Services, ``Ownership,
Financing, and Management Strategies of the 10 largest for-profit
nursing home chains in the United States,'' Charlene Harrington et al.,
2011, https://www.ncbi.nlm.nih.gov/pubmed/22053531; Kaiser Family
Foundation, ``Reading the Stars: Nursing Home Quality Star Ratings,
Nationally and by State,'' May 2015, http://files.kff.org/attachment/
issue-brief-reading-the-stars-nursing-home-quality-star-ratings-
nationally-and-by-state.
Nursing homes provide a wide range of important medical and personal
care services to a growing and vulnerable elderly population, with 1.3
million residents in the United States currently receiving care in more
than 15,000 facilities.\2\ For decades, reports and data have
highlighted the shocking living conditions found in many nursing home
and other long-term care facilities across the country.\3\ Twelve years
ago, for example, journalists uncovered how a group of private
investment firms acquired 49 nursing homes, including a facility in
Florida where managers slashed the number of registered nurses by half
and cut supply and activity budgets. Residents, meanwhile, suffered
from preventable infections and injuries.\4\ Last year, news reports
similarly detailed how a for-profit nursing home employed drastic cost
cutting measures, ``exposed its roughly 25,000 patients to increasing
health risk,'' and ultimately filed for bankruptcy--all after a private
equity firm acquired the company.\5\
---------------------------------------------------------------------------
\2\ National Center for Health Statistics, ``Long-term Care
Providers and Services Users in the United States, 2015-2016,''
February 2019, https://www.cdc.gov/nchs/data/series/sr_03/sr03_43-
508.pdf.
\3\ New York Times, ``At Many Homes, More Profit and Less
Nursing,'' Charles Duhigg, September 23, 2017, https://www.nytimes.com/
2007/09/23/business/23nursing.html; Reveal, ``The rats sensed she was
going to pass away,'' Jennifer Gollan, September 18, 2019, https://
www.revealnews.org/article/elderly-often-face-neglect-in-california-
care-homes-that-exploit-workers/.
\4\ New York Times, ``At Many Homes, More Profit and Less
Nursing,'' Charles Duhigg, September 23, 2017, https://www.nytimes.com/
2007/09/23/business/23nursing.html.
\5\ Washington Post, ``Overdoses, bedsores, broken bones: What
happened when a private-equity firm sought to care for society's most
vulnerable,'' Peter Whoriskey and Dan Keating, November 25, 2018,
https://www.washingtonpost.com/business/economy/opioid-overdoses-
bedsores-and-broken-bones-what-happened-when-a-private-equity-firm-
sought-profits-in-caring-for-societys-most
-vulnerable/2018/11/25/09089a4a-ed14-11e8-baac-2a674e91502b_story.html.
This is particularly concerning given the fact that two-thirds of
nursing home residents rely on government-sponsored health insurance
coverage, meaning both not-for-profit and for-profit nursing homes
benefit from government funding.\6\ Medicaid is the primary payer \7\
for nursing home care, with Medicare and Medicaid combined covering
approximately 75 percent of nursing home residents.\8\ In 2015,
taxpayers sent more than $55 billion to the nursing home industry to
cover the costs of long-term care. These reports and corresponding
research raise serious questions about the role of private equity firms
in the nursing home care industry, and the extent to which these firms'
emphasis on profits and short-term return is responsible for declines
in quality of care. They also raise concerns over the stewardship of
taxpayer dollars, when--in many cases--these facilities continue to
receive Medicare and Medicaid funding despite their decline in quality.
---------------------------------------------------------------------------
\6\ Kaiser Family Foundation, ``Distribution of Certified Nursing
Facility Residents by Primary Payer Source,'' accessed on Nov. 14,
2019, https://www.kff.org/other/state-indicator/distribution-of-
certified-nursing-facilities-by-primary-payer-source/
?currentTimeframe=O&sortModel=%7
B%22colId%22:%22Location%22.%22sort%22:%22asc%22%7D.
\7\ Kaiser Family Foundation, ``Medicaid's Role in Nursing Home
Care,'' June 20,2017, https://www.kff.org/infographic/medicaids-role-
in-nursing-home-care/.
\8\ Kaiser Family Foundation, ``Distribution of Certified Nursing
Facility Residents by Primary Payer Source,'' accessed on Nov. 14,
2019, https://www.kff.org/other/state-indicator/distribution-of-
certified-nursing-facilities-by-primary-payer-source/
?currentTimeframe=O&sortModel=%7
B%22colld%22:%22Location%22,%22sort%22:%22asc%22%7D.
The majority of nursing facilities--almost 70%--are for-profit, and
over half are chain-affiliated.\9\ The overwhelming majority of
research conducted over the last 2 decades shows that for-profit and
chain affiliated \10\ companies provide a lower quality of care and
experience more serious health and safety deficiencies when compared to
non-profit facilities.\11\
---------------------------------------------------------------------------
\9\ National Center for Health Statistics, ``Long-term Care
Providers and Services Users in the United States, 2015-2016,''
February 2019, https://www.cdc.gov/nchs/data/series/sr_03/sr03_43-
508.pdf.
\10\ Facilities owned or leased by ``an organization that owns two
or more long-term care facilities.''
\11\ International Journal of Health Services, ``Ownership,
Financing, and Management Strategies of the ten largest for-profit
nursing home chains in the United States,'' Charlene Harrington et al.,
2011; Medical Care Research and Review, ``Nursing home profit status
and quality of care: Is there any evidence of an association?'',
Michael P. Hillmer et al., April 2005, https://www.ncbi.nlm.nih.gov/
pubmed/15750174.
Additionally, for-profit facilities receive the lowest scores in the
Centers for Medicare and Medicaid Services' (CMS) nursing home rating
system that takes into account, state health inspections, staffing
ratios and quality measures. \12\
---------------------------------------------------------------------------
\12\ Kaiser Family Foundation, ``Reading the Stars: Nursing Home
Quality Star Ratings, Nationally and by State,'' May 2015, http://
files.kff.org/attachment/issue-brief-reading-the-stars-nursing-home-
quality-star-ratings-nationallyand-by-state.
Private equity investment appears to exacerbate the problems faced at
chain-
affiliated for-profit nursing homes. Studies show that private equity-
owned facilities generally ``deliver poorer quality of care'' than
other chain-affiliated for-profit facilities; are likely to try to
reduce cost by ``substituting expensive but skilled RNs with cheaper
and less skilled nurses;'' and ``report significantly higher number of
deficiencies'' that climb with more years of private equity ownership.
As a result, private equity-owned nursing homes have 21% higher
deficiencies, 25% lower nursing staff skill mix, and ``worse results on
pressure sore prevention . . . and [higher] pressure ulcer [] risk
prevalence.''\13\ That was reportedly the case at HCR ManorCare--the
second largest for-profit nursing home chain in the United States. In
the years following its acquisition by a private equity firm, ``the
number of citations increased for, among other things, neither
preventing nor treating bed sores; medication errors; not providing
proper care for people who need special services such as injections,
colostomies and prostheses; and not assisting patients with eating and
personal hygiene.''\14\
---------------------------------------------------------------------------
\13\ Journal of Health Care Finance, ``Private Equity Ownership of
Nursing Homes: Implications for Quality,'' Rohit Pradhan et al., June-
July 2014, http://healthfinancejournal.com/index.php/johcf/article/
view/12.
\14\ Washington Post, ``Overdoses, bedsores, broken bones: What
happened when a private-
equity firm sought to care for society's most vulnerable,'' Peter
Whoriskey and Dan Keating, November 25, 2018, https://
www.washingtonpost.com/business/economy/opioid-overdoses-bedsores-and-
broken-bones-what-happened-when-a-private-equity-firm-sought-profits-
in-caring-for-societys-most-vulnerable/2018/11/25/09089a4a-ed14-11e8-
baac-2a674e91502b_story.html.
Moreover, while the quality of service declines, the complicated
ownership and operating structure of these investments ``limit legal
remedies available to aggrieved residents.''\15\ For example, after a
resident died at the private-equity-owned Habana Health Care Center (as
a result of ``a wound [that] should have been detected much earlier''),
a family member tried to sue the owners of the facility, only to
discover that the facility's complicated ownership structure ``meant
that even if she prevailed in court, the investors' wallets would
likely be out of reach.''\16\ Shifting funds to other affiliated
entities, or to the private equity firm itself, to immunize itself from
liability for judgments against a target company is a widespread
practice in the private equity industry.
---------------------------------------------------------------------------
\15\ Journal of Health Care Finance, ``Private Equity Ownership of
Nursing Homes: Implications for Quality,'' Rohit Pradhan et al., June-
July 2014, http://healthfinancejournal.com/index.php/johcf/article/
view/12.
\16\ New York Times, ``At Many Homes, More Profit and Less
Nursing,'' Charles Duhigg, September 23, 2007, https://www.nytimes.com/
2007/09/23/business/23nursing.html.
Private equity investment in this sector has increased over the last
few decades. The Government Accountability Office found that over the
span of 10 years ending in 2008, private investment firms acquired
approximately 1,900 unique nursing homes.\17\ Today, private equity
firms own or operate several large for-profit chains that control
hundreds of facilities and provide nursing home care among other long-
term care services.\18\ Formation reportedly owns or has had
investments in companies providing nursing home care. In order to help
us understand your firm's role in the nursing home sector, we ask that
you provide answers to the following questions no later than November
29, 2019.
---------------------------------------------------------------------------
\17\ Government Accountability Office, ``Nursing Homes: Complexity
of Private Investment Purchases Demonstrates Need for CMS to Improve
the Usability and Completeness of Ownership Data,'' September 2010,
https://www.gao.gov/assets/320/310562.pdf.
\18\ IQVIA, ``U.S. Elder Care Market Summary,'' September 2019,
https://www.skainfo.com/reports/u.s.-elder-care-market-summary.
1. Please provide the disclosure documents and information
enumerated in Sections 501 and 503 of the Stop Wall Street Looting
Act.\19\
---------------------------------------------------------------------------
\19\ Stop Wall Street Looting Act, S. 2155, https://
www.congress.gov/bill/116th-congress/senate-bill/2155.
2. Which nursing home or other long-term care service companies,
including all affiliates or related entities, does Formation have a
stake in or own? Please provide the name of and a brief description of
the services each company provides--including the number of facilities
---------------------------------------------------------------------------
that it owns or operates.
a. Which nursing home or other long-term care companies,
including all affiliates or related entities, has Formation had a stake
in or owned in the past 20 years? Please provide the name of and a
brief description of the services each company provides or provided-
including the number of nursing home and other long-term care
facilities that it owned or operated.
b. For each nursing home or other long-term care service
company Formation had a stake in or owned in the past 20 years,
including all affiliates or related entities, please provide the
following information for each year that the firm have had a stake in
or owned this company and the 5 years preceding the firm's investment.
i. The name of the company
ii. Total number of facilities, by type of facility
iii. Ownership stake
iv. Total revenue, and the total revenue from Medicare, and
from Medicaid
v. Total transaction, advisory, or other fees collected
after the acquisition of the company
vi. Net income
vii. Total number of employees for each facility
viii. Total number of patients for each facility, and the
total number whose care is paid for by Medicare, and by Medicaid
ix. Other private-equity firms that own a stake in the
company pany
3. Private-equity firms reportedly employ sale-leaseback
arrangements in order to quickly recover investments. For each company
listed in questions 2(a) and 2(b), please list the number of nursing
home or other long-term care facilities for which you acquired real
estate assets, and whether a sale-leaseback agreement has been executed
for any of those companies or facilities.
4. Has any nursing home or other long-term care company,
including all affiliates or related entities, in which Formation has an
ownership stake or has had an ownership stake in the last 20 years
received Section 232 Department of Housing and Urban Development (HUD)-
insured mortgages? If so, please provide the name of each facility and
the total value of each loan insured by HUD.
5. Has any nursing home or other long-term care company,
including all affiliates or related entities, in which Formation has an
ownership stake or has had an ownership stake in the last 20 years,
been placed in receivership? Please provide the name of each facility.
6. Has any nursing home or other long-term care company,
including all affiliates or related entities, in which Formation has an
ownership stake or has had an ownership stake in the last 20 years,
been found to have violated any federal or state laws or regulations?
If so, please provide a complete list, including the date and
description, of all such violations. Please also include a list of all
deficiencies identified in state or federal surveys of the facilities
owned by the company for each year.
7. Has any nursing home or other long-term care company,
including all affiliates or related entities, in which Formation has an
ownership stake or has had an ownership stake in the last 20 years,
reached a settlement with any federal or state law enforcement entity
related to a potential violation of any federal or state laws or
regulations or deficiencies in providing care? If so, please provide a
complete list, including the date and description, of all such
settlements.
8. Has any nursing home or other long-term care company,
including all affiliates or related entities, in which Formation has an
ownership stake or has had an ownership stake in the past 20 years,
reached a settlement with any individual who was provided services by
the company related to a potential violation of any federal or state
laws or regulations or deficiencies in providing care? If so, please
provide a complete list, including the date and description, of all
such settlements.
Thank you for your attention to this matter.
Sincerely,
Elizabeth Warren Mark Pocan
United States Senator United States Congress
Sherrod Brown
United States Senator
______
Congress of the United States
Washington, DC 20510
November 15, 2019
Ronald E. Silva
President and Chief Executive Officer
Fillmore Capital Partners
Four Embarcadero Center, Suite 710
San Francisco, CA 94111
Dear Mr. Silva:
We are writing to request information regarding Fillmore Capital
Partners' (Fillmore) investment in companies providing nursing home
care and other long-term care services and to request information about
your firm's structure and finances as it relates to these companies.
Private equity funds often operate under a model where they purchase
controlling interests in companies for a short time, load them up with
debt, strip them of their assets, extract exorbitant fees, and sell
them at a profit--implementing drastic cost-cutting measures at the
expense of consumers, workers, communities, and taxpayers. For that
reason, we have concerns about the rapid spread and effect of private
equity investment in many sectors of the economy, especially industries
that affect vulnerable populations and rely primarily on taxpayer-
funded programs such as Medicare and Medicaid, like the nursing home
industry. We are particularly concerned about your firm's investment in
large for-profit nursing home chains, which research has shown often
provide worse care than not-for-profit facilities.\1\ In light of these
concerns, we request information about your firm, the portfolio
companies in which it has invested, and the performance of those
investments.
---------------------------------------------------------------------------
\1\ International Journal of Health Services, ``Ownership,
Financing, and Management Strategies of the 10 largest for-profit
nursing home chains in the United States,'' Charlene Harrington et al.,
2011, https://www .ncbi.nlm.nih.gov/pubmed/22053531; Kaiser Family
Foundation, ``Reading the Stars: Nursing Home Quality Star Ratings,
Nationally and by State,'' May 2015, http://files.kff.org/attachment/
issue-brief-reading-the-stars-nursing-home-quality-star-ratings-
nationally-and-by-state.
Nursing homes provide a wide range of important medical and personal
care services to a growing and vulnerable elderly population, with 1.3
million residents in the United States currently receiving care in more
than 15,000 facilities.\2\ For decades, reports and data have
highlighted the shocking living conditions found in many nursing home
and other long-term care facilities across the country.\3\ Twelve years
ago, for example, journalists uncovered how a group of private
investment firms acquired 49 nursing homes, including a facility in
Florida where managers slashed the number of registered nurses by half
and cut supply and activity budgets. Residents, meanwhile, suffered
from preventable infections and injuries.\4\ Last year, news reports
similarly detailed how a for-profit nursing home employed drastic cost
cutting measures, ``exposed its roughly 25,000 patients to increasing
health risk,'' and ultimately filed for bankruptcy--all after a private
equity firm acquired the company.\5\
---------------------------------------------------------------------------
\2\ National Center for Health Statistics, ``Long-term Care
Providers and Services Users in the United States, 2015-2016,''
February 2019, https://www.cdc.gov/nchs/data/series/sr_03/sr03_43-
508.pdf.
\3\ New York Times, ``At Many Homes, More Profit and Less
Nursing,'' Charles Duhigg, September 23, 2017, https://www.nytimes.com/
2007/09/23/business/23nursing.html; Reveal, ``The rats sensed she was
going to pass away,'' Jennifer Gollan, September 18, 2019, https://
www.revealnews.org/article/elderly-often-face-neglect-in-california-
care-homes-that-exploit-workers/.
\4\ New York Times, ``At Many Homes, More Profit and Less
Nursing,'' Charles Duhigg, September 23, 2017, https://www.nytimes.com/
2007/09/23/business/23nursing.html.
\5\ Washington Post, ``Overdoses, bedsores, broken bones: What
happened when a private-equity firm sought to care for society's most
vulnerable,'' Peter Whoriskey and Dan Keating, November 25, 2018,
https://www.washingtonpost.com/business/economy/opioid-overdoses-
bedsores-and-broken-bones-what-happened-when-a-private-equity-firm-
sought-profits-in-caring-for-societys-most-vulnerable/2018/11/25/
09089a4a-ed14-11e8-baac-2a674e91502b_story.html.
This is particularly concerning given the fact that two-thirds of
nursing home residents rely on govenunent-sponsored health insurance
coverage, meaning both not-for-profit and for-profit nursing homes
benefit from government funding.\6\ Medicaid is the primary payer \7\
for nursing home care, with Medicare and Medicaid combined covering
approximately 75 percent of nursing home residents.\8\ In 2015,
taxpayers sent more than $55 billion to the nursing home industry to
cover the costs of long-term care. These reports and corresponding
research raise serious questions about the role of private equity firms
in the nursing home care industry, and the extent to which these firms'
emphasis on profits and short-term return is responsible for declines
in quality of care. They also raise concerns over the stewardship of
taxpayer dollars, when--in many cases--these facilities continue to
receive Medicare and Medicaid funding despite their decline in quality.
---------------------------------------------------------------------------
\6\ Kaiser Family Foundation. ``Distribution of Certified Nursing
Facility Residents by Primary Payer Source,'' accessed on Nov. 14,
2019, https://www.kff.org/other/state-indicator/distribution-of-
certified-nursing-facilities-by-primary-payer-source/
?currentTimeframe=O&sortModel=%7
B%22colId%22:%22Location%22.%22sort%22:%22asc%22%7D.
\7\ Kaiser Family Foundation, ``Medicaid's Role in Nursing Home
Care,'' June 20, 2017, https://www.kff.org/infographic/medicaids-role-
in-nursing-home-care/.
\8\ Kaiser Family Foundation, ``Distribution of Certified Nursing
Facility Residents by Primary Payer Source,'' accessed on Nov. 14,
2019, https://www.kff.org/other/state-indicator/distribution-of-
certified-nursing-facilities-by-primary-payer-source/
?currentTimeframe=O&sortModel=%7
B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.
The majority of nursing facilities--almost 70%--are for-profit, and
over half are chain-affiliated.\9\ The overwhelming majority of
research conducted over the last 2 decades shows that for-profit and
chain affiliated \10\ companies provide a lower quality of care and
experience more serious health and safety deficiencies when compared to
non-profit facilities.\11\ Additionally, for-profit facilities receive
the lowest scores in the Centers for Medicare and Medicaid Services'
(CMS) nursing home rating system that takes into account, state health
inspections, staffing ratios and quality measures.\12\
---------------------------------------------------------------------------
\9\ National Center for Health Statistics, ``Long-term Care
Providers and Services Users in the United States, 2015-2016,''
February 2019, https://www.cdc.gov/nchs/data/series/sr_03/sr03_43-
508.pdf.
\10\ Facilities owned or leased by ``an organization that owns two
or more long-term care facilities.''
\11\ International Journal of Health Services, ``Ownership,
Financing, and Management Strategies of the 10 largest for-profit
nursing home chains in the United States,'' Charlene Harrington et al.,
2011; Medical Care Research and Review, ``Nursing home profit status
and quality of care: Is there any evidence of an association?'',
Michael P. Hillmer et al., Apri1 2005, https://www.ncbi.nlm.nih.gov/
pubmed/15750174.
\12\ Kaiser Family Foundation, ``Reading the Stars: Nursing Home
Quality Star Ratings, Nationally and by State,'' May 2015, http://
files.kff.org/attachment/issue-brief-reading-the-stars-nursing-home-
quality-star-ratings-nationally-and-by-state.
Private equity investment appears to exacerbate the problems faced at
chain-
affiliated for-profit nursing homes. Studies show that private equity-
owned facilities generally ``deliver poorer quality of care'' than
other chain-affiliated for-profit facilities; are likely to try to
reduce cost by ``substituting expensive but skilled RNs with cheaper
and less skilled nurses;'' and ``report significantly higher number of
deficiencies'' that climb with more years of private equity ownership.
As a result, private equity-owned nursing homes have 21% higher
deficiencies, 25% lower nursing staff skill mix, and ``worse results on
pressure sore prevention . . . and [higher] pressure ulcer [] risk
prevalence.''\13\ That was reportedly the case at HCR ManorCare--the
second largest for-profit nursing home chain in the United States. In
the years following its acquisition by a private equity firm, ``the
number of citations increased for, among other things, neither
preventing nor treating bed sores; medication errors; not providing
proper care for people who need special services such as injections,
colostomies and prostheses; and not assisting patients with eating and
personal hygiene.''\14\
---------------------------------------------------------------------------
\13\ Journal of Health Care Finance, ``Private Equity Ownership of
Nursing Homes: Implications for Quality,'' Rohit Pradhan et al., June-
July 2014, http://healthfinancejournal.com/index.php/johcf/article/
view/12.
\14\ Washington Post, ``Overdoses, bedsores, broken bones: What
happened when a private-
equity firm sought to care for society's most vulnerable,'' Peter
Whoriskey and Dan Keating, November 25, 2018, https://
www.washingtonpost.com/business/economy/opioid-overdoses-bedsores-and-
broken-bones-what-happened-when-a-private-equity-firm-sought-profits-
in-caring-for-societys-most-vulnerable/2018/11/25/09089a4a-ed14-11e8-
baac-2a674e91502b_story.html.
Moreover, while the quality of service declines, the complicated
ownership and operating structure of these investments ``limit legal
remedies available to aggrieved residents.''\15\ For example, after a
resident died at the private-equity-owned Habana Health Care Center (as
a result of ``a wound [that] should have been detected much earlier''),
a family member tried to sue the owners of the facility, only to
discover that the facility's complicated ownership structure ``meant
that even if she prevailed in court, the investors' wallets would
likely be out of reach.''\16\ Shifting funds to other affiliated
entities, or to the private equity firm itself, to immunize itself from
liability for judgments against a target company is a widespread
practice in the private equity industry.
---------------------------------------------------------------------------
\15\ Journal of Health Care Finance, ``Private Equity Ownership of
Nursing Homes: Implications for Quality,'' Rohit Pradban et al., June-
July 2014, http://healthfinancejournal.com/index.php/johcf/article/
view/12.
\16\ New York Times, ``At Many Homes, More Profit and Less
Nursing,'' Charles Duhigg, September 23, 2007, https://www.nytimes.com/
2007/09/23/business/23nursing.html.
Private equity investment in this sector has increased over the last
few decades. The Government Accountability Office found that over the
span of 10 years ending in 2008, private investment firms acquired
approximately 1,900 unique nursing homes.\17\ Today, private equity
firms own or operate several large for-profit chains that control
hundreds of facilities and provide nursing home care among other long-
term care services.\18\ Fillmore reportedly owns or has had investments
in companies providing nursing home care. In order to help us
understand your firm's role in the nursing home sector, we ask that you
provide answers to the following questions no later than November 29,
2019.
---------------------------------------------------------------------------
\17\ Government Accountability Office, ``Nursing Homes: Complexity
of Private Investment Purchases Demonstrates Need for CMS to Improve
the Usability and Completeness of Ownership Data,'' September 2010,
https://www.gao.gov/assets/320/310562.pdf.
\18\ IQVIA, ``U.S. Elder Care Market Summary,'' September 2019,
https://www.skainfo.com/reports/u.s.-elder-care-market-summary.
1. Please provide the disclosure documents and information
enumerated in Sections 501 and 503 of the Stop Wall Street Looting
Act.\19\
---------------------------------------------------------------------------
\19\ Stop Wall Street Looting Act, S. 2155, https://
www.congress.gov/bill/116th-congress/senate-bill/2155.
2. Which nursing home .or other long-term care service
companies, including all affiliates or related entities, does Fillmore
have a stake in or own? Please provide the name of and a brief
description of the services each company provides--including the number
---------------------------------------------------------------------------
of facilities that it owns or operates.
a. Which nursing home or other long-term care companies,
including all affiliates or related entities, has Fillmore had a stake
in or owned in the past 20 years? Please provide the name of and a
brief description of the services each company provides or provided--
including the number of nursing home and other long-term care
facilities that it owned or operated.
b. For each nursing home or other long-term care service
company Fillmore had a stake in or owned in the past 20 years,
including all affiliates or related entities, please provide the
following information for each year that the firm have had a stake in
or owned this company and the 5 years preceding the firm's investment.
i. The name of the company
ii. Total number of facilities, by type of facility
iii. Ownership stake
iv. Total revenue, and the total revenue from Medicare, and
from Medicaid
v. Total transaction, advisory, or other fees collected
after the acquisition of the company
vi. Net income
vii. Total number of employees for each facility
viii. Total number of patients for each facility, and the
total number whose care is paid for by Medicare, and by Medicaid
ix. Other private-equity firms that own a stake in the
company
3. Private-equity firms reportedly employ sale-leaseback
arrangements in order to quickly recover investments. For each company
listed in questions 2(a) and 2(b), please list the number of nursing
home or other long-term care facilities for which you acquired real
estate assets, and whether a sale-leaseback agreement has been executed
for any of those companies or facilities.
4. Has any nursing home or other long-term care company,
including all affiliates or related entities, in which Fillmore has an
ownership stake or has had an ownership stake in the last 20 years
received Section 232 Department and Urban Development (HUD)-insured
mortgages? If so, please provide the name of each facility and the
total value of each loan insured by HUD.
5. Has any nursing home or other long-term care company,
including all affiliates or related entities, in which Fillmore has an
ownership stake or has had an ownership stake in the last 20 years,
been placed in receivership? Please provide the name of each facility.
6. Has any nursing home or other long-term care company,
including all affiliates or related entities, in which Fillmore has an
ownership stake or has had an ownership stake in the last 20 years,
been found to have violated any federal or state laws or regulations?
If so, please provide a complete list, including the date and
description, of all such violations. Please also include a list of all
deficiencies identified in state or federal surveys of the facilities
owned by the company for each year.
7. Has any nursing home or other long-term care company,
including all affiliates or related entities, in which Fillmore has an
ownership stake or has had an ownership stake in the last 20 years,
reached a settlement with any federal or state law enforcement entity
related to a potential violation of any federal or state laws or
regulations or deficiencies in providing care? If so, please provide a
complete list, including the date and description, of all such
settlements.
8. Has any nursing home or other long-term care company,
including all affiliates or related entities, in which Fillmore has an
ownership stake or has had an ownership stake in the past 20 years,
reached a settlement with any individual who was provided services by
the company related to a potential violation of any federal or state
laws or regulations or deficiencies in providing care? If so, please
provide a complete list, including the date and description, of all
such settlements.
Thank you for your attention to this matter.
Sincerely,
Elizabeth Warren Mark Pocan
United States Senator United States Congress
Sherrod Brown
United States Senator
______
Congress of the United States
Washington, DC 20510
November 15, 2019
Charles R. Kaye
Co-Chief Executive Officer
Warburg Pincus LLC
450 Lexington Ave.
New York, NY 10017
Joseph P. Landy
Co-Chief Executive Officer
Warburg Pincus LLC
450 Lexington Ave.
New York, NY 10017
Dear Messrs. Kaye and Landy:
We are writing to request information regarding Warburg Pincus LLC's
(Warburg Pincus) investment in companies providing nursing home care
and other long-term care services and to request information about your
firm's structure and finances as it relates to these companies.
Private equity funds often operate under a model where they purchase
controlling interests in companies for a short time, load them up with
debt, strip them of their assets, extract exorbitant fees, and sell
them at a profit -implementing drastic cost-cutting measures at the
expense of consumers, workers, communities, and taxpayers. For that
reason, we have concerns about the rapid spread and effect of private
equity investment in many sectors of the economy, especially industries
that affect vulnerable populations and rely primarily on taxpayer-
funded programs such as Medicare and Medicaid, like the nursing home
industry. We are particularly concerned about your firm's investment in
large for-profit nursing home chains, which research has shown often
provide worse care than not-for-profit facilities.\1\ In light of these
concerns, we request information about your firm, the portfolio
companies in which it has invested, and the performance of those
investments.
---------------------------------------------------------------------------
\1\ International Journal of Health Services, ``Ownership,
Financing, and Management Strategies of the 10 largest for-profit
nursing home chains in the United States,'' Charlene Harrington et al.,
2011, https://www.ncbi.nlm.nih.gov/pubmed/22053531; Kaiser Family
Foundation, ``Reading the Stars: Nursing Home Quality Star Ratings,
Nationally and by State,'' May 2015, http://files.kff.org/attachment/
issue-brief-reading-the-stars-nursing-home-quality-star-ratings-
nationally-and-by-state.
Nursing homes provide a wide range of important medical and personal
care services to a growing and vulnerable elderly population, with 1.3
million residents in the United States currently receiving care in more
than 15,000 facilities.\2\ For decades, reports and data have
highlighted the shocking living conditions found in many nursing home
and other long-term care facilities across the country.\3\ Twelve years
ago, for example, journalists uncovered how a group of private
investment firms acquired 49 nursing homes, including a facility in
Florida where managers slashed the number of registered nurses by half
and cut supply and activity budgets. Residents, meanwhile, suffered
from preventable infections and injuries.\4\ Last year, news reports
similarly detailed how a for-profit nursing home employed drastic cost
cutting measures, ``exposed its roughly 25,000 patients to increasing
health risk,'' and ultimately filed for bankruptcy--all after a private
equity firm acquired the company.\5\
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\2\ National Center for Health Statistics, ``Long-term Care
Providers and Services Users in the United States, 2015-2016,''
February 2019, https://www.cdc.gov/nchs/data/series/sr_03/sr03_43-
508.pdf.
\3\ New York Times, ``At Many Homes, More Profit and Less
Nursing,'' Charles Duhigg, September 23, 2017, https://www.nytimes.com/
2007/09/23/business/23nursing.html; Reveal, ``The rats sensed she was
going to pass away,'' Jennifer Gollan, September 18, 2019, https://
www.revealnews.org/article/elderly-often-face-neglect-in-california-
care-homes-that-exploit-workers/.
\4\ New York Times, ``At Many Homes, More Profit and Less
Nursing,'' Charles Duhigg, September 23, 2017, https://www.nytimes.com/
2007/09/23/business/23nursing.html.
\5\ Washington Post, ``Overdoses, bedsores, broken bones: What
happened when a private-equity firm sought to care for society's most
vulnerable,'' Peter Whoriskey and Dan Keating, November 25, 2018,
https://www.washingtonpost.com/business/economy/opioid-overdoses-
bedsores-and-broken-bones-what-happened-when-a-private-equity-firm-
sought-profits-in-caring-for-societys-most-vulnerable/2018/11/25/
09089a4a-ed14-11e8-baac-2a674e91502b_story.html.
This is particularly concerning given the fact that two-thirds of
nursing home residents rely on government-sponsored health insurance
coverage, meaning both not-for-profit and for-profit nursing homes
benefit from government funding.\6\ Medicaid is the primary payer \7\
for nursing home care, with Medicare and Medicaid combined covering
approximately 75 percent of nursing home residents.\8\ In 2015,
taxpayers sent more than $55 billion to the nursing home industry to
cover the costs of long-term care. These reports and corresponding
research raise serious questions about the role of private equity firms
in the nursing home care industry, and the extent to which these firms'
emphasis on profits and short-term return is responsible for declines
in quality of care. They also raise concerns over the stewardship of
taxpayer dollars, when--in many cases--these facilities continue to
receive Medicare and Medicaid funding despite their decline in quality.
---------------------------------------------------------------------------
\6\ Kaiser Family Foundation, ``Distribution of Certified Nursing
Facility Residents by Primary Payer Source,'' accessed on Nov. 14,
2019, https://www.kff.org/other/state-indicator/distribution-of-
certified-nursing-facilities-by-primary-payer-source/
?currentTimeframe=O&sortModel=%7
B%22colId%22:%22Location%22.%22sort%22:%22asc%22%7D.
\7\ Kaiser Family Foundation, ``Medicaid's Role in Nursing Home
Care,'' June 20,2017, https://www.kff.org/infographic/medicaids-role-
in-nursing-home-care/.
\8\ Kaiser Family Foundation, ``Distribution of Certified Nursing
Facility Residents by Primary Payer Source,'' accessed on Nov. 14,
2019, https://www.kff.org/other/state-indicator/distribution-of-
certified-nursing-facilities-by-primary-payer-source/
?currentTimeframe=O&sortModel=%7
B%22colId%22:%22Location%22.%22sort%22:%22asc%22%7D.
The majority of nursing facilities--almost 70%--are for-profit, and
over half are chain-affiliated.\9\ The overwhelming majority of
research conducted over the last 2 decades shows that for-profit and
chain affiliated\10\ companies provide a lower quality of care and
experience more serious health and safety deficiencies when compared to
non-profit facilities.\11\
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\9\ National Center for Health Statistics, ``Long-term Care
Providers and Services Users in the United States, 2015-2016,''
February 2019, https://www.cdc.gov/nchs/data/series/sr_03/sr03_43-
508.pdf.
\10\ Facilities owned or leased by ``an organization that owns two
or more long-term care facilities.''
\11\ International Journal of Health Services, ``Ownership,
Financing, and Management Strategies of the 10 largest for-profit
nursing home chains in the United States,'' Charlene Harrington et al.,
2011; Medical Care Research and Review, ``Nursing home profit status
and quality of care: Is there any evidence of an association?'',
Michael P. Hillmer et al., April 2005, https://www.ncbi.nlm.nih.gov/
pubmed/15750174.
Additionally, for-profit facilities receive the lowest scores in the
Centers for Medicare and Medicaid Services' (CMS) nursing home rating
system that takes into account, state health inspections, staffing
ratios and quality measures.\12\
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\12\ Kaiser Family Foundation, ``Reading the Stars: Nursing Home
Quality Star Ratings, Nationally and by State,'' May 2015, http://
files.kff.org/attachment/issue-brief-reading-the-stars-nursing-home-
quality-star-ratings-nationally-and-by-state.
Private equity investment appears to exacerbate the problems faced at
chain-
affiliated for-profit nursing homes. Studies show that private equity-
owned facilities generally ``deliver poorer quality of care'' than
other chain-affiliated for-profit facilities; are likely to try to
reduce cost by ``substituting expensive but skilled RNs with cheaper
and less skilled nurses;'' and ``report significantly higher number of
deficiencies'' that climb with more years of private equity ownership.
As a result, private equity-owned nursing homes have 21% higher
deficiencies, 25% lower nursing staff skill mix, and ``worse results on
pressure sore prevention . . . and [higher] pressure ulcer [] risk
prevalence.''\13\ That was reportedly the case at HCR ManorCare--the
second largest for-profit nursing home chain in the United States. In
the years following its acquisition by a private equity firm, ``the
number of citations increased for, among other things, neither
preventing nor treating bed sores; medication errors; not providing
proper care for people who need special services such as injections,
colostomies and prostheses; and not assisting patients with eating and
personal hygiene.''\14\
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\13\ Journal of Health Care Finance, ``Private Equity Ownership of
Nursing Homes: Implications for Quality,'' Rohit Pradhan et al., June-
July 2014, http://healthfinancejournal.com/index.php/johcf/article/
view/12.
\14\ Washington Post, ``Overdoses, bedsores, broken bones: What
happened when a private-
equity firm sought to care for society's most vulnerable,'' Peter
Whoriskey and Dan Keating, November 25, 2018, https://
www.washingtonpost.com/business/economy/opioid-overdoses-bedsores-and-
broken-bones-what-happened-when-a-private-equity-firm-sought-profits-
in-caring-for-societys-most-vulnerable/2018/11/25/09089a4a-ed14-11e8-
baac-2a674e91502b_story.html.
Moreover, while the quality of service declines, the complicated
ownership and operating structure of these investments ``limit legal
remedies available to aggrieved residents.''\15\ For example, after a
resident died at the private-equity-owned Habana Health Care Center (as
a result of ``a wound [that] should have been detected much earlier''),
a family member tried to sue the owners of the facility, only to
discover that the facility's complicated ownership structure ``meant
that even if she prevailed in court, the investors' wallets would
likely be out of reach.''\16\ Shifting funds to other affiliated
entities, or to the private equity firm itself, to immunize itself from
liability for judgments against a target company is a widespread
practice in the private equity industry.
---------------------------------------------------------------------------
\15\ Journal of Health Care Finance, ``Private Equity Ownership of
Nursing Homes: Implications for Quality,'' Rohit Pradhan et al., June-
July 2014, http://healthfinancejournal.com/index.php/johcf/article/
view/12.
\16\ New York Times, ``At Many Homes, More Profit and Less
Nursing,'' Charles Duhigg, September 23, 2007, https://www.nytimes.com/
2007/09/23/business/23nursing.html.
Private equity investment in this sector has increased over the last
few decades. The Government Accountability Office found that over the
span of 10 years ending in 2008, private investment firms acquired
approximately 1,900 unique nursing homes.\17\ Today, private equity
firms own or operate several large for-profit chains that control
hundreds of facilities and provide nursing home care among other long-
term care services.\18\ Warburg Pincus reportedly owns or has had
investments in companies providing nursing home care. In order to help
us understand your firm's role in the nursing home sector, we ask that
you provide answers to the following questions no later than November
29, 2019.
---------------------------------------------------------------------------
\17\ Government Accountability Office, ``Nursing Homes: Complexity
of Private Investment Purchases Demonstrates Need for CMS to Improve
the Usability and Completeness of Ownership Data,'' September 2010,
https://www.gao.gov/assets/320/310562.pdf.
\18\ IQVIA, ``U.S. Elder Care Market Summary,'' September 2019,
https://www.skainfo.com/reports/u.s.-elder-care-market-summary.
1. Please provide the disclosure documents and information
enumerated in Sections 501 and 503 of the Stop Wall Street Looting
Act.\19\
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\19\ Stop Wall Street Looting Act, S. 2155, https://
www.congress.gov/bill/116th-congress/senate-bill/2155.
2. Which nursing home or other long-term care service companies,
including all affiliates or related entities, does Warburg Pincus have
a stake in or own? Please provide the name of and a brief description
of the services each company provides--including the number of
---------------------------------------------------------------------------
facilities that it owns or operates.
a. Which nursing home or other long-term care companies,
including all affiliates or related entities, has Warburg Pincus had a
stake in or owned in the past 20 years? Please provide the name of and
a brief description of the services each company provides or provided--
including the number of nursing home and other long-term care
facilities that it owned or operated.
b. For each nursing home or other long-term care service
company Warburg Pincus had a stake in or owned in the past 20 years,
including all affiliates or related entities, please provide the
following information for each year that the firm have had a stake in
or owned this company and the 5 years preceding the firm's investment.
i. The name of the company
ii. Total number of facilities, by type of facility
iii. Ownership stake
iv. Total revenue, and the total revenue from Medicare, and
from Medicaid
v. Total transaction, advisory, or other fees collected
after the acquisition of the company
vi. Net income
vii. Total number of employees for each facility
viii. Total number of patients for each facility, and the
total number whose care is paid for by Medicare, and by Medicaid
ix. Other private-equity firms that own a stake in the
company
3. Private-equity firms reportedly employ sale-leaseback
arrangements in order to quickly recover investments. For each company
listed in questions 2(a) and 2(b), please list the number of nursing
home or other long-term care facilities for which you acquired real
estate assets, and whether a sale-leaseback agreement has been executed
for any of those companies or facilities.
4. Has any nursing home or other long-term care company,
including all affiliates or related entities, in which Warburg Pincus
has an ownership stake or has had an ownership stake in the last 20
years received Section 232 Department of Housing and Urban Development
(HUD)-insured mortgages? If so, please provide the name of each
facility and the total value of each loan insured by HUD.
5. Has any nursing home or other long-term care company,
including all affiliates or related entities, in which Warburg Pincus
has an ownership stake or has had an ownership stake in the last 20
years, been placed in receivership? Please provide the name of each
facility.
6. Has any nursing home or other long-term care company,
including all affiliates or related entities, in which Warburg Pincus
has an ownership stake or has had an ownership stake in the last 20
years, been found to have violated any federal or state laws or
regulations? If so, please provide a complete list, including the date
and description, of all such violations. Please also include a list of
all deficiencies identified in state or federal surveys of the
facilities owned by the company for each year.
7. Has any nursing home or other long-term care company,
including all affiliates or related entities, in which Warburg Pincus
has an ownership stake or has had an ownership stake in the last 20
years, reached a settlement with any federal or state law enforcement
entity related to a potential violation of any federal or state laws or
regulations or deficiencies in providing care? If so, please provide a
complete list, including the date and description, of all such
settlements.
8. Has any nursing home or other long-term care company,
including all affiliates or related entities, in which Warburg Pincus
has an ownership stake or has had an ownership stake in the past 20
years, reached a settlement with any individual who was provided
services by the company related to a potential violation of any federal
or state laws or regulations or deficiencies in providing care? If so,
please provide a complete list, including the date and description, of
all such settlements.
Thank you for your attention to this matter.
Sincerely,
Elizabeth Warren Mark Pocan
United States Senator United States Congress
Sherrod Brown
United States Senator
______
Fillmore Capital Partners LLC
Four Embarcadero Center, Suite 710
San Francisco CA 94111
T: 415-834-1477
F: 415-834-1475
https://www.fillmorecap.com/
December 18, 2019
The Honorable Elizabeth Warren
The Honorable Sherrod Brown
Mark Pocan, Member of Congress
Congress of the United States
Washington DC 20510
RE: United States Congress--Letter of November 15, 2019
Dear Senator Warren, Senator Brown and Congressman Pocan:
This will confirm receipt of an electronic copy of your above-
referenced letter directed to Fillmore Capital Partners in which you
make certain representations about private equity companies and request
information about Fillmore Capital Partners and affiliates. In
preparing for response, we explored the basis for your written request
for detailed proprietary information. I note that in your role as
Democratic members of the House and Senate you have proposed a bill
entitled the ``Stop Wall Street Looting Act of 2019'' with the goal of
enhancing government scrutiny of the private equity sector. Your letter
to Fillmore Capital Partners advocates for the points you believe
support passage of the Act and requests information that would
presumably be used as part of the effort to pass this Act. Please find
below my response to your letter, which is tailored to your request and
the circumstances, based on information readily available at this time.
First, I would like to share a high level review of my observations
of the nursing home industry as a whole so that we have the proper
context here. In my opinion it is counterproductive to paint any sector
with a broad-brush, be it the investment or nursing home sector. I have
personal experience with the healthcare industry as a caregiver to my
mom and dad, both veterans of WWII, as well as countless other family
members and friends. To hold the hand of the dying is both difficult
and life changing. In addition to my role with Fillmore, I have served
as a board chairperson for several ownership companies, some of which
had affiliations with the long-term care industry and the operation of
nursing homes. These are my general observations as an individual,
caregiver, trustee of an IDD individual and as a board chairperson.
It should come as no surprise to you that I disagree with the
portrayal of individuals and businesses affiliated with the private
equity sector and nursing home industry as ``uncaring'' and ``profit-
seeking.'' The nursing home industry and healthcare providers in
general in this Country employ some of the most hardworking and caring
citizens in the U.S. Every day 24/7/365, healthcare providers touch the
lives of tens of millions of individuals and families, many of which
are your constituents, in an attempt to provide care, comfort and
solutions. With respect to nursing or long-term care, in most cases
these are patients whose family could not care for them or would not
care for them. They are patients who were ready to discharge from
hospitals with no place to go. They are patients with mental and
physical conditions in need of the services that only a nursing home is
willing to provide. They are for the most part, our elderly population
who have little to no income, living on the edge of life with no
alternatives. For profit and non-profit nursing home operators serve
our communities whether they be urban, suburban or in rural parts of
the U.S. Many providers do so with 50 plus year-old facilities, limited
financial resources, outdated regulations, labor and skill challenges,
enduring general disdain from the uninformed. As my Marine Corps mother
said at 87, ``getting old ain't for the faint of heart.'' Nursing home
operators have provided services in States with Medicaid reimbursement
rates that do not even cover the actual costs of the care provided to
citizens of their State, yet operators have often continued to provide
the resources needed to support those locations. In some communities
the nursing facility is the only healthcare resource, the largest
employer, and even provides coffee for local first responders. Nursing
homes, and the caregivers in them, have served and continue to serve as
a critical resource for the elderly and infirm U.S. population.
As you are aware, effective in 2012 Congress reduced planned
Medicare reimbursement rates for nursing homes in by 11.1%. At the time
the then President of the Alliance for Quality Nursing Home Care stated
that lawmakers would as a result be ``faced with an increased threat to
local seniors' access to care.'' Recent closure of nursing facilities
in rural areas in multiple States has in fact threatened seniors'
access to care. Without question rural communities will continue to
struggle with access to healthcare, long-term care, medication
management and hospice care. Industry leaders with whom I have spoken,
have grave concerns regarding how the future needs of the baby boomer
elderly will be met given the current lack of Federal and State support
for the nursing home industry in the U.S. Adequate funding is needed to
help your constituents who have to rely on government funding to
receive care. Much like the aging infrastructure issue this Country
faces with regard to housing for those with low income, the physical
plant locations for many nursing homes are reaching the end of their
useful life. Industry leaders have cautioned that given the current
economic realities, even with State, Federal and private sector
support, it is doubtful that providers will be able to develop new or
replace old facilities. It cannot be disputed that the industry is
already one of the most heavily regulated, scrutinized and targeted for
litigation in the Country. Without changes in reimbursement to offset
escalating costs overall, many facilities that are needed by the senior
population simply will not survive.
With regard to your specific requests for information, the first
requests information that could be required in the event the Act were
passed. Because the Act has not passed we are not educated about the
requirements of the Act and are not in a position to respond to this
request. The response to request #2(a) is simple and is already known
to CMS and most State SNF licensure authorities. The response to
requests #2(b) through #8 involves asking affiliates of Fillmore
Capital to gather a significant amount of information, much of which
has already been provided to government agencies and is otherwise
publicly available. As of this date the Fillmore and Golden Living
affiliated Golden Living Center operators no longer operate nursing
homes. Therefore, those affiliates have limited personnel to locate and
retrieve the information requested. I can, however, provide some basic
information that I have obtained, such as for #4 I am not aware of any
HUD financing related to Golden Living Centers; for #5, no Golden
Living Center licensed operator was placed in receivership at any time;
for #6, very few, if any, operators could answer `no' as the nursing
home industry is very heavily regulated and frequently assessed fines
for alleged violations. CMS has public data readily available to you
from which you can identify nursing facility surveys. #7 and #8 request
information subject to confidentiality obligations which our affiliates
with very limited resources would have to research.
I have noticed that numerous references cited in your letter are
sources that have for many years criticized and opposed both nursing
home operators and their affiliated holding companies/owners. They have
pure disdain for what caregivers do, many in aging facilities with few
modern amenities. Of course, nursing home providers care for your
Medicaid constituents, generally frail and declining with numerous
health challenges 24/7/365 for less than $140 per day and, as my mother
would once again say, that ain't for the faint of heart! I hope you
will find this response beneficial. I am willing to make time to
further discuss this and attempt to create understanding in order to
replace disdain. It is also my understanding that there are many
nursing home operator representatives who are willing to work closely
with Congress to share information and pursue solutions that are in the
overall best interest of your constituents.
Finally, as an example of the positive impact investors can have on
the healthcare industry, please review the websites of two Fillmore
affiliated healthcare organizations which are defying the odds to
successfully provide needed state-of-the-art services, www.Salude.com
and www.alixarx.com. Salude is a specially constructed skilled nursing
facility which is ranked by CMS as the #1 skilled nursing care facility
in the U.S., out of 15,000 nationally. AlixaRx is a unique remote
automated pharmacy solution developed for nursing care, to make needed
medications more readily available in rural communities by providing
on-demand medication and patient medication management. Unfortunately,
these concepts are not likely to come to your communities soon as they
require financial resources beyond what are currently available in most
States and communities in order to succeed.
With Respect,
Ronald E. Silva
President and CEO
______
Akin Gump
strauss hauer and feld llp
RAPHAEL A. PROBER
202-887-4319/fax: 202-887-4288
[email protected]
confidential treatment requested
November 29, 2019
VIA E-MAIL
The Honorable Elizabeth Warren
United States Senate
9 Hart Senate Office Building
Washington, DC 20510
The Honorable Sherrod Brown
United States Senate
503 Hart Senate Office Building
Washington, DC 20510
The Honorable Mark Pocan
United States House of Representatives
1421 Longworth House Office Building
Washington, DC 20510
Re: November 15, 2019 Letter to Warburg Pincus, LLC
Dear Senator Warren, Senator Brown, and Congressman Pocan:
On behalf of Warburg Pincus, LLC (``Warburg Pincus''), we write in
response to your letter dated November 15, 2019 (the ``Letter'') in
which you requested information regarding investments made by funds
managed by Warburg Pincus in skilled nursing facilities.
Funds managed by Warburg Pincus, since its founding in 1966, have made
over 150 healthcare investments. In the last 20 years, only two
investments made by funds managed by Warburg Pincus were in the skilled
nursing home care industry; the first of which was exited in 2002 and
the second of which was exited in 2011. Since 2011, no fund managed by
Warburg Pincus has made or held any investments in skilled nursing
facilities. Below, please find information on the investments exited in
2002 and 2011, which constitute the only investments covered by your
Letter.\1\
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\1\ Funds managed by Warburg Pincus also invested in two companies
focused on the assisted living industry, Brandywine Senior Care
(invested in 2006, exited in 2010) and The Covenant Group (invested in
2007, exited in 2011).
Since its founding in 1966, Warburg Pincus has predominantly pursued a
strategy of growth investing at scale, with the vast majority of the
investments made in growth stage or early stage companies. Over the
years, funds managed by Warburg Pincus have successfully invested in
growth companies as well as companies at other stages of development,
from building early-stage and start-up companies, to providing capital
to meet the needs of existing businesses and, to a lesser extent, to
investing in later-stage transactions and special situations, typically
in circumstances in which growth is a key aspect of the investment
thesis. The firm's early-stage and growth investing approach is thesis-
driven, pursuing extensively researched themes and ideas. The firm also
prefers to invest with accomplished management teams who are investing
in the transactions alongside the firm. As evidence of the firm's
successful focus on growth investing, the firm's portfolio investments
---------------------------------------------------------------------------
have completed over 170 initial public offerings.
Warburg Pincus aims to build lasting companies that will perform well
in growing industries--the goal in every investment is to create a
larger, thriving business by making long-term investments and creating
value. Warburg Pincus believes that this approach positions the
investors in the funds it manages, which include pension funds that
benefit multiple categories of public and private employees, to receive
attractive risk-adjusted long-term returns over the course of economic
and capital markets cycles.
In 2000, funds managed by Warburg Pincus invested in Centennial
Healthcare Corporation (``Centennial''). At the time, Centennial was a
publicly traded operator of approximately 100 skilled nursing
facilities, of which 6 were owned, 64 were leased, and 30 were managed,
and had operations in 22 states. During that period, the skilled
nursing home care industry was severely challenged due to, among other
things, reduced reimbursement rates, high leverage, high labor costs
due to a labor shortage, and high litigation expenses due to industry-
wide regulatory issues and increasing patient liability tort claims.
Four of the seven largest home chains had filed for bankruptcy, with a
fifth imminent (which subsequently also filed for bankruptcy).
Centennial itself faced these challenges. Warburg Pincus's investment
thesis was that the industry was poised to recover due to, among other
things, an increasing demand for long-term nursing care because of an
aging population. In light of that investment thesis, funds managed by
Warburg Pincus acquired approximately 52% of Centennial in 2000, with
management and other investors (Welsh Carson and South Atlantic
Capital) owning the rest. Despite management's efforts to turn
Centennial around in this challenging environment, the company filed
for bankruptcy in 2002. No dividends were paid to any fund managed by
Warburg Pincus during the period of ownership, nor did Warburg Pincus
itself charge or collect any transaction, advisory or other fees,
consistent with the firm's long-standing practice not to charge such
fees for any services provided by Warburg Pincus employees to portfolio
companies.
Based on the same investment thesis for Centennial, funds managed by
Warburg Pincus co-founded Florida Healthcare Properties (``Florida
Healthcare'') in 2001, owning approximately 75% of the company during
much of its ownership tenure, with other health care executives and
management owning the rest. Over time, Florida Healthcare came to
operate approximately 127 skilled nursing facilities in 17 states and
the District of Columbia. Sale-leasebacks were not part of the
company's business model--the company leased almost all of its
facilities from third parties. The funds managed by Warburg Pincus
exited their investment in Florida Healthcare in 2011. (The company's
name had since been changed to Lavie Care Centers.) Once again, Warburg
Pincus did not charge or collect any transaction, advisory or other
fees.
Warburg Pincus's involvement in the operations of its portfolio
companies, like Centennial and Florida Healthcare, is that of an
investor. While Warburg Pincus nominees often sit on the boards of
directors of its portfolio companies (and held seats on the boards of
directors of both Centennial and Florida Healthcare during the periods
of ownership), the role and responsibility of such board
representatives is one of oversight of the company's executive
management team and assistance in the strategic direction of the
company. The executive management teams of portfolio companies are
responsible for the day-to-day operations of the portfolio companies.
As a general matter, the information provided to board members is
designed to assist them in discharging their oversight duties.
We hope the information that Warburg Pincus has provided herein with
respect to the two investments exited nearly a decade ago is helpful to
your review.
* * * * *
The information and data included in this response contains sensitive
information--including confidential and proprietary information--and we
request that such information be treated accordingly and that it not be
released to any third parties. Production of this information and data
is not intended to constitute a waiver of the attorney-client, attorney
work product, or any other applicable rights or privileges in this or
any other forum, and Warburg Pincus expressly reserves its rights in
this regard.
Sincerely,
Raphael A. Prober
Counsel for Warburg Pincus
______
The Carlyle Group
1001 Pennsylvania Avenue, NW, Suite 220
Washington, DC 20004-2505
Tel (202) 729-5626 Fax (202) 347-1818
https://www.carlyle.com/
November 29, 2019
Senator Elizabeth Warren
309 Hart Senate Office Building
Washington, DC 20510-4543
Senator Sherrod Brown
503 Hart Senate Office Building
Washington, DC 20510-4543
Congressman Mark Pocan
1421 Longworth House Office Building
Washington, DC 20510-4543
Dear Senators Warren, Brown and Congressman Pocan:
We received your inquiry dated November 15, 2019 regarding The Carlyle
Group's investments in companies providing nursing home care and other
long-term care services. We appreciate your interest in the subject.
The Carlyle Group (``Carlyle'') is a global investment firm with deep
industry expertise that deploys private capital across four business
segments: Corporate Private Equity, Real Assets, Global Credit, and
Investment Solutions. With $222 billion of assets under management,
Carlyle's purpose is to invest wisely and create value on behalf of its
investors, many of whom are public pensions. Carlyle has expertise in
various industries, including aerospace, defense and government
services, consumer and retail, energy and power, financial services,
healthcare, industrial, real estate, technology and business services,
telecommunications and media, and transportation. The portfolio
companies owned by Carlyle investment funds employ 900,000 people
globally and more than 100,000 in the United States. Since its founding
in 1987, the firm has invested $103 billion in 643 Corporate Private
Equity transactions. More than 2,600 investors from 94 countries
entrust Carlyle with their capital.
The healthcare sector has been a core focus area for Carlyle for over
25 years. Carlyle's investments in healthcare companies have spanned
geographies--including North America, Europe, South America, and Asia--
and subsectors within healthcare--including leading providers of
clinical care, preeminent research organizations, reliable
manufacturers of medical devices and pharmaceutical products, and
reputable service providers that facilitate access to timely and high-
quality care. Our portfolio of investments, within healthcare and
across other industries, also spans investment strategies, including
investing in growth-oriented companies to support their expansions.
Regardless of the geography, subsector, or investment strategy, we seek
to invest behind healthcare companies that can capitalize on growth
opportunities, drive better health outcomes for patients, and bring
improvements to the healthcare system. As part of our investment
process, we also evaluate the environmental, social, and governance
aspects of a company, which takes into consideration key stakeholders,
including patients, payors, customers, and employees.
Today, neither Carlyle nor any nor its investment funds owns any equity
interest in any company that operates nursing facilities \1\ in the
United States.\2\ In 2007, an investment fund managed by Carlyle
acquired a majority equity investment in HCR ManorCare, Inc. (``the
Company'' or ``HCR''), which operated skilled nursing, assisted living
and home healthcare facilities. Carlyle never managed the operations of
the company. However, employees of Carlyle served as members of the
Board of Directors of HCR, and the Board of Directors ensured that the
Company had appropriate policies and procedures in place to assess and
address clinical quality at HCR's facilities. For example, under
Carlyle's ownership, HCR ManorCare established an Independent Advisory
Committee on Quality, which provided advice and recommendations to the
Company's Board of Directors on ways to measure, maintain and improve
quality care for HCR ManorCare patients and residents.
---------------------------------------------------------------------------
\1\ See the Nursing Home Compare site of medicare.gov: ``Nursing
home is a term that includes both skilled nursing facilities and
nursing facilities. Skilled nursing facilities (SNF) are those that
participate in both Medicare and Medicaid. Nursing facilities (NF) arc
those that participate in Medicaid only. Nursing homes primarily engage
in providing residents skilled nursing care and related services for
residents who require medical or nursing care and rehabilitation
services for the rehabilitation of injured, disabled, or sick
individuals.'' (https://www.
medicare.gov/NursingHomeCompare/Resources/Glossary.html)
\2\ Carlyle Real Estate funds do hold investments in real estate on
which private pay senior living communities, independent communities
and assisted living communities are operated. However, the companies in
which Carlyle's Real Estate funds hold investments do not operate these
facilities.
During Carlyle's ownership, quality and care delivery remained a key
priority for the Company.\3\ From 2007-2017, HCR's total staffing,
hands on caregiving staff and nursing staff all increased. The Centers
for Medicare and Medicaid Services (``CMS'') rated HCR ManorCare's
regulatory compliance above industry average. At the time of Carlyle's
exit, HCR ManorCare's CMS Five Star Rating \4\ Data show that the
facilities were at or above industry average for overall, quality
measures, staffing and registered nurse staffing. In fact, most of the
centers received four or five stars. From 2013-2017, HCR ManorCare's
serious safety incident rate was better than the national average in
each and every year. During the same period, the average CMS quality
measure star rating was considered outstanding by CMS, with 88% of
centers receiving four or five stars.
---------------------------------------------------------------------------
\3\ All data referenced in this letter provided to Carlyle by HCR
ManorCare.
\4\ The Centers for Medicare and Medicaid Services created the
Five-Star Rating System to allow consumers to assess nursing homes on
health inspections, staffing and quality measures.
Management of real estate assets is a necessary part of operating in
the nursing facility industry, and, during Carlyle's ownership, HCR,
like other companies in the industry, engaged in a number of
transactions involving its real estate holdings. Those transactions
included a 2011 sale-lease-back transaction in which HCP, Inc. acquired
a portion of HCR's real estate assets and leased those facilities back
to HCR. HCP, Inc. subsequently transferred those assets to Quality Care
---------------------------------------------------------------------------
Properties, Inc.
Following our initial investment, several legislative events and CMS
actions created reimbursement headwinds that negatively impacted the
company's financial performance. These measures reduced the company's
reimbursement and/or increased its costs by hundreds of millions of
dollars. As an example, Medicare rates for the industry and HCR for
2019 are lower than they were in 2011 due to rate cuts and changes in
rate methodology. The entire skilled nursing facility industry has been
negatively affected by these changes. In fact, The Medicare Payment
Advisory Committee (MedPAC), the agency that provides the U.S. Congress
with analysis and policy advice, estimated the margin for the entire
skilled nursing facility industry was less than 1.0% in 2017.\5\
Numerous other companies in the industry have filed for bankruptcy,
exited long-term care or were financially distressed during this time,
including Genesis, Signature, Extendicare, Skyline, Kindred, Golden
Living and Consulate.
---------------------------------------------------------------------------
\5\ Per MedPAC March 2019 Report to Congress.
Given these changes in reimbursement, HCR ManorCare had been working on
a plan to recapitalize its balance sheet in a manner designed to
promote the long-term financial health of the Company and maintain
quality of care. For legal reasons, the company filed for pre-packaged
bankruptcy in 2018. Patient care was not compromised. All creditors and
employees continued to be paid during the bankruptcy proceedings and
not a single creditor (other than the Company's landlord, Quality Care
Properties) lost capital as a result of the bankruptcy filing. As a
result of this restructuring, HCR ManorCare became a wholly owned
subsidiary of ProMedica Health System in 2018. Carlyle owns no interest
in either HCR ManorCare or ProMedcia. ProMedica, an acute care health
system, bought HCR ManorCare because it is a high-quality provider.
ProMedica would not have acquired HCR if it did not believe that HCR
---------------------------------------------------------------------------
provides high quality patient care.
Carlyle takes pride in its approach to responsible investing. We thank
you for your inquiry in this subject.
Sincerely,
Stacey Dion
Managing Director, Global Government Affairs
______
Prepared Statement of Hon. Mike Crapo,
a U.S. Senator From Idaho
At the national, State and local levels, the pandemic has
challenged our sense of normalcy. It has tested every institution of
daily life we know, threatening the physical and economic health of our
Nation. Americans from all walks of life have experienced a year full
of tremendous hardship and tragedy. It is the people living and working
in our Nation's nursing homes, however, who bore an outsized burden.
More than 174,000 people died as COVID-19 ravaged our long-term
care facilities. That number represents almost one-third of all U.S.
deaths that have occurred during the pandemic.
Both long-stay nursing homes and short-stay post-acute skilled
nursing facilities rely on direct care workers--such as licensed
practical nurses, certified nursing assistants, and personal care
aides--to provide most hands-on care. These workers are in close
physical contact with residents, assisting with bathing, dressing, and
eating. Current data shows that long-term care workers are typically
female, and a disproportionate share are women of color.
Many of these direct care workers live paycheck to paycheck. Over
the past year, they have put their lives on the line. We owe them a
debt of gratitude. Thank you to the dedicated nursing home workers like
Adelina Ramos, one of our witnesses.
These workers hear Americans calling them heroes, but they are
often under-
appreciated when on the job. To these front-line workers, please know
that the sacrifices you are making every day do not go unnoticed or
unappreciated.
Today, we will hear from a number of expert witnesses who will
provide key insights into nursing home conditions over the past year.
This testimony will help us better understand exactly what happened,
when it happened, and why it happened. It will give us insight into
policies that produced results, as well as areas that need improvement.
Hearings are just one oversight tool this committee uses to hold
government agencies, the health-care industry, and individual providers
accountable. Another key part of oversight is securing reliable and
accurate data. Transparent data reporting brings accountability and
helps drive decision-making. As we look to the future, it is vital that
all States report accurate COVID-19 data. That is the only way for
economists, researchers, advocacy organizations, and policy-makers to
tackle the challenges facing the nursing home sector head-on.
This is not a job for the Federal Government alone. Multiple
Federal, State, and local programs and partnerships work to support the
health-care needs of our Nation's most vulnerable populations. We must
work together--in an honest and transparent manner--to safeguard our
nursing home residents and the workers who care for them.
Over the weekend, The New York Times published the results of an
investigation into the Centers for Medicare and Medicaid Services (CMS)
nursing home five-star rating system. The investigation questions the
objectivity and accuracy of the CMS star ratings system. This rating
system, which was first implemented during the Obama administration, is
designed to help beneficiaries, their families, and caregivers compare
nursing home quality more easily.
Care Compare is another online tool available to help seniors, the
disabled, and their families find out if a particular nursing home
facility meets Federal health and safety standards, staffing levels,
and quality performance metrics.
After several bipartisan hearings held by the Finance Committee
during 2019, CMS implemented changes to Nursing Home Compare that
specifically denote nursing homes that have been cited for incidents of
abuse, neglect, or exploitation. That may have been a start, but
clearly there is a lot more work that needs to be done.
I am grateful to each of our witnesses for the work that they are
doing and for taking the time to join us today. Their expertise will
help us advance public policies that slow the spread of COVID-19 and
lessen its devastating impacts on our Nation's elderly and the
disabled.
______
Prepared Statement of John E. Dicken, Director,
Health Care, Government Accountability Office
COVID-19 in Nursing Homes: HHS Has Taken Steps in Response to Pandemic,
but Several GAO Recommendations Have Not Been Implemented
Why GAO Did This Study
The COVID-19 pandemic has had a disproportionate impact on the 1.4
million elderly or disabled residents in the Nation's more than 15,000
Medicare- and
Medicaid-certified nursing homes, who are often in frail health and
living in close proximity to one another. HHS, primarily through CMS
and CDC, has led the pandemic response in nursing homes.
The CARES Act includes a provision for GAO to conduct monitoring
and oversight of the Federal Government's efforts to prepare for,
respond to, and recover from the COVID-19 pandemic. GAO has examined
the government's response to COVID-19 in nursing homes through its
CARES Act reporting (GAO-21-265, GAO-21-191, GAO-20-701, and GAO-20-
625).
This testimony will summarize the findings from these reports.
Specifically, it describes COVID-19 trends in nursing homes and their
experiences responding to the pandemic, and HHS's response to the
pandemic in nursing homes.
To conduct this previously reported work, GAO reviewed CDC data,
agency guidance, and other relevant information on HHS's response to
the COVID-19 pandemic. GAO interviewed agency officials and other
knowledgeable stakeholders. In addition, GAO supplemented this
information with updated data from CDC on COVID-19 cases and deaths
reported by nursing homes as of February 2021.
What GAO Found
GAO's review of data from the Centers for Disease Control and
Prevention (CDC) found that winter 2020 was marked by a significant
surge in the number of COVID-19 cases and deaths in nursing homes.
However, CDC data as of February 2021, show that both cases and deaths
have declined by more than 80 percent since their peaks in December
2020. With the introduction of vaccines, observers are hopeful that
nursing homes may be beginning to see a reprieve.Nevertheless, the
emergence of more highly transmissible virus variants warrants the need
for continued vigilance, according to public health officials.
GAO's prior work has found that nursing homes have faced many
difficult challenges battling COVID-19. While challenges related to
staffing shortages have persisted through the pandemic, challenges
related to obtaining Personal Protective Equipment (PPE) and conducting
COVID-19 tests--although still notable--have generally shown signs of
improvement since summer 2020. Further, with the decline in nursing
homes cases, the Centers for Medicare and Medicaid Services (CMS)
updated its guidance in March 2021 to expand resident visitation, an
issue that has been an ongoing challenge during the pandemic. Some new
challenges have also emerged as vaccinations began in nursing homes,
such as reluctance among some staff to receive a COVID-19 vaccine.
The Department of Health and Human Services (HHS), primarily
through CMS and the CDC, has taken steps to address COVID-19 in nursing
homes. However, HHS has not implemented several relevant GAO
recommendations, including:
HHS has not implemented GAO's recommendation related to the
Nursing Home Commission report, which assessed the response to COVID-19
in nursing homes. CMS released the Nursing Home Commission's report and
recommendations in September 2020. When the report was released, CMS
broadly outlined the actions the agency had taken, but the agency did
not provide a plan that would allow it to track its progress. GAO
recommended in November 2020 that HHS develop an implementation plan.
As of February 2021, this recommendation had not been implemented.
HHS has not implemented GAO's recommendation to fill COVID-19
data voids. CMS required nursing homes to begin reporting the number of
cases and deaths to the agency effective May 8, 2020. However, CMS made
the reporting of the data prior to this date optional. GAO recommended
in September 2020 that HHS develop a strategy to capture more complete
COVID-19 data in nursing homes retroactively back to January 1, 2020.
As of February 2021, this recommendation had not been implemented.
Implementing GAO's recommendations could help address some of the
challenges nursing homes continue to face and fill important gaps in
the Federal Government's understanding of, and transparency around,
data on COVID-19 in nursing homes. In addition to monitoring HHS's
implementation of past recommendations, GAO has ongoing work related to
COVID-19 outbreaks in nursing homes and CMS's oversight of infection
control and emergency preparedness.
_______________________________________________________________________
Chairman Wyden, Ranking Member Crapo, and members of the committee:
I am pleased to be here today to discuss our work on Coronavirus
Disease 2019 (COVID-19) in nursing homes. Just over a year ago, a
Washington State nursing home was battling one of the first major
COVID-19 outbreaks in the United States. Today, the COVID-19 pandemic
has reached nearly all of the more than 15,000 Medicare- and Medicaid-
certified nursing homes in the country, resulting in a
disproportionately high number of COVID-19 deaths among residents.
While the Nation's 1.4 million nursing home residents are a small share
of the total U.S. population (less than 1 percent), they comprise
nearly 30 percent of COVID-19 deaths reported by the Centers for
Disease Control and Prevention (CDC). Nursing home residents are at a
high risk for COVID-19 infection and death because the virus has a high
mortality rate among elderly adults and those with underlying health
conditions. In addition, the congregate nature of nursing homes, with
staff caring for multiple residents and shared communal spaces, as well
as high incidence rates in the surrounding community, can increase the
risk that COVID-19 will enter the home and easily spread. Further,
efforts to reduce the spread of COVID-19 in nursing homes have required
changes in typical nursing home practices--such as restricting visitors
and isolating residents exposed to COVID-19--raising concerns for
vulnerable residents, who may have less social interaction and third
party oversight of their care.
The Centers for Medicare and Medicaid Services (CMS), an agency
within the Department of Health and Human Services (HHS), is
responsible for ensuring that nursing homes meet Federal quality
standards to participate in the Medicare and Medicaid programs.\1\ In
response to the pandemic, HHS, primarily through CMS and CDC, has taken
a series of actions with nursing homes, such as providing guidance,
developing targeted inspections to improve infection control practices,
and distributing testing devices to homes.\2\ In addition, in May 2020,
CDC began collecting weekly COVID-19 data from nursing homes through
its National Healthcare Safety Network system.
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\1\ To monitor compliance with these standards, CMS enters into
agreements with State survey agencies in each State government to
conduct inspections, including recurring comprehensive standard surveys
and as-needed investigations. CMS's Center for Clinical Standards and
Quality has responsibility for overseeing State survey agencies' survey
and certification activities, among others.
\2\ In our May 2020 report, we found that infection control
deficiencies were widespread and persistent in nursing homes in the
years prior to the COVID-19 pandemic. See GAO, Infection Control
Deficiencies Were Widespread and Persistent in Nursing Homes Prior to
COVID-19 Pandemic, GAO-20-576R, (Washington, DC: May 20, 2020).
The CARES Act includes a provision for us to conduct monitoring and
oversight of the Federal Government's efforts to prepare for, respond
to, and recover from the COVID-19 pandemic.\3\ In response to the CARES
Act, we have examined the response to COVID-19 in nursing homes in four
reports since June 2020. To help inform today's discussion, my
testimony will summarize our findings on nursing home issues from these
reports.\4\ In particular, my statement will address:
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\3\ Pub. L. No. 116-139, Sec. 19010(b), 134 Stat. 281, 579 (2020).
\4\ See GAO, COVID-19: Critical Vaccine Distribution, Supply Chain,
Program Integrity, and Other Challenges Require Focused Federal
Attention, GAO-21-265 (Washington, DC: January 28, 2021); COVID-19:
Urgent Actions Needed to Better Ensure an Effective Federal Response,
GAO-21-191 (Washington, DC: November 30, 2020); COVID-19: Federal
Efforts Could Be Strengthened by Timely and Concerted Actions, GAO-20-
701 (Washington, DC: September 21, 2020); and COVID-19: Opportunities
to Improve Federal Response and Recovery Efforts, GAO-20-625
(Washington, DC: June 25, 2020).
1. COVID-19 trends in nursing homes and their experiences
---------------------------------------------------------------------------
responding to the COVID-19 pandemic, and
2. HHS's response to the COVID-19 pandemic in nursing homes.
In addition, I will highlight key actions that we recommended HHS
take and the current status of those recommendations. While my comments
today focus on the findings of our CARES Act reports, they are also
informed by our longer-term body of work examining nursing home
oversight and quality prior to the pandemic.
To conduct the work for the previously issued reports on which my
comments are based, we reviewed CDC data, agency guidance, and other
relevant information on HHS's response to the COVID-19 pandemic. We
interviewed agency officials, as well as researchers with experience in
infection control, advocates for individuals residing in nursing homes
and their families, national associations representing nursing homes,
and representatives from associations representing State and local
officials. More detailed information on our methodology can be found in
the issued reports.\5\ In addition, we supplemented this information
with updated data from CDC on COVID-19 reported by nursing homes for
the week ending February 7, 2021.\6\ We analyzed the CDC data as they
were reported by nursing homes to CDC and publicly posted by CMS. We
did not otherwise independently verify the accuracy of the information
with these nursing homes. We assessed the reliability of the data sets
used in our analyses by checking for missing values and obvious errors
and reviewing relevant CMS and CDC documents. We determined the data
were sufficiently reliable for the purposes of our reporting objective.
---------------------------------------------------------------------------
\5\ For example, see GAO-21-265.
\6\ We analyzed the most recent data available on February 18,
2021. The CDC data on COVID-19 in nursing homes were accessed on
February 18, 2021, for the week ending February 7, 2021, from https://
data.cms.gov/Covid19-nursing-home-data. For the data on COVID-19 in
nursing homes, we analyzed and reported data that had been determined
by CDC and CMS to pass quality assurance checks for data entry errors.
According to CDC, data used in this analysis are part of a live data
set, meaning that facilities can make corrections to the data at any
time.
We conducted the work on which this statement is based in
accordance with generally accepted government auditing standards. Those
standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.
nursing home covid-19 cases and deaths are declining after winter
surge; persistent challenges remain in pandemic response
After a Winter Surge, CDC Data Show a Decline in COVID-19 Cases and
Deaths Among Nursing Home Residents and Staff to Levels Closer
to Those of Fall 2020
Our analysis of CDC data shows that winter 2020 was marked by a
significant surge in the number of COVID-19 cases and deaths for
nursing home residents and staff. Specifically, during mid-December
2020, there were more than 33,600 new resident cases and 28,600 new
staff cases, which was more than twice as high as the prior case number
peaks in summer 2020. CDC data show that cases and deaths in nursing
homes are on the decline. Specifically, as of the week ending February
7, 2021, resident and staff cases have both declined by more than 80
percent since their peaks in December 2020. The changing weekly COVID-
19 death counts in nursing homes generally moved in the same direction
as changes in the country as a whole. With the introduction of
vaccines, observers are hopeful that nursing homes may be beginning to
see a reprieve; however, the emergence of more highly transmissible
virus variants warrants the need for continued vigilance, according to
public health officials.\7\ (See fig. 1).
---------------------------------------------------------------------------
\7\ These numbers are likely underreported because they do not
include data for the 998 nursing homes (6.5 percent) that did not
report COVID-19 data to CDC for the week ending February 7, 2021, or
that submitted data that failed data quality assurance checks. The week
ending May 31, 2020 is the first single week of data reported to CDC.
The week ending May 24th is the only earlier week of data, and could
potentially include cases and deaths for multiple weeks dating back to
January 1, 2020, for those homes which voluntarily reported such data.
It is therefore not comparable with data for other weeks, and we
excluded it. According to CDC, data used in this analysis are part of a
live data set, meaning that facilities can make corrections to the data
at any time.
[GRAPHIC] [TIFF OMITTED] T1721.025
.epsNotes: Dates refer to the end of a week (e.g., May 31 refers to
---------------------------------------------------------------------------
the entire week from May 25th through May 31st).
According to CDC, data used in this analysis are part of a live
data set, meaning that facilities can make corrections to the data at
any time. Data presented reflect the data downloaded as of February 18,
2021, which includes data through the week ending February 7, 2021. We
excluded data for the week ending May 24, 2020, because it is the first
week for which data are available from the CDC and could include cases
and deaths from multiple weeks dating back to January 1, 2020.
Weekly and cumulative case and death counts are likely
underreported because they do not include data for the nursing homes
that did not report COVID-19 data to CDC for that week or from nursing
homes that submitted data that failed data quality assurance checks.
Additionally, as we previously reported, the Centers for Medicare and
Medicaid Services (CMS) does not require nursing homes to report data
prior to May 2020, although nursing homes may do so voluntarily. We
recommended that the Secretary of Health and Human Services-in
consultation with CMS and CDC-develop a strategy to capture more
complete data on confirmed COVID-19 cases and deaths in nursing homes
retroactively to January 1, 2020. See GAO, COVID-19: Federal Efforts
Could Be Strengthened by Timely and Concerted Actions, GAO-20-701
(Washington, DC: September 21, 2020).
Weekly staff deaths reported for the weeks ending May 31st through
February 7th ranged from 13 (week ending September 20, 2020) to 61
(week ending May 31, 2020).
Some Challenges Nursing Homes Faced Persisted While Other New
Challenges Have Emerged
In our prior CARES Act reports, we found that nursing homes have
faced many difficult challenges battling COVID-19.\8\ While challenges
related to staffing shortages have persisted through the pandemic,
challenges related to obtaining Personal Protective Equipment (PPE) and
conducting COVID-19 tests--although still notable--have generally shown
signs of improvement since summer 2020. Further, with the decline in
nursing home cases, CMS updated its guidance in March 2021 to expand
resident visitation, an issue that has been an ongoing and persistent
challenge during the pandemic. Some new challenges have also emerged as
vaccinations started for nursing home residents and staff. (See table
1). Some of these challenges, such as staffing shortages, obtaining
PPE, and conducting testing, are critically important for infection
control.
---------------------------------------------------------------------------
\8\ See GAO-20-701; GAO-21-265; GAO-21-191; and GAO-20-625.
Table 1: Key Pandemic Challenges Experienced by Nursing Homes
------------------------------------------------------------------------
Challenge Description Status
------------------------------------------------------------------------
Visitation Through interviews with researchers, Challenge has
advocacy organizations, and persisted
national association officials from throughout
July 2020 to February 2021, we pandemic
consistently heard that nursing
homes have faced an ongoing tension
between providing residents with
important visitation and minimizing
the potential for a COVID-19
outbreak:
The restriction of visitors has
negatively affected residents'
mental and physical health.
Researchers and advocacy
organizations have noted that the
isolation resulting from decreased
visitation can cause loneliness,
anxiety, and depression among
residents.
The restriction of visitors has
created limited oversight of
facilities through the exclusion of
resident advocates, such as family
members and ombudsmen.
------------------------------------------------------------------------
Staffing In our reviews of data from the Challenge has
Centers for Disease Control and persisted
Prevention (CDC) and interviews throughout
with advocacy organization and pandemic
national association officials from
July 2020 through January 2021, we
consistently found that nursing
home staffing challenges were
difficult and ongoing throughout
the pandemic:
CDC data from July through
December 2020 consistently show
that about one in five nursing
homes were reporting to CDC that
they had a shortage of nurse aides
or other support staff.a
From nursing home associations we
interviewed, we heard that many
alternative staffing sources have
been used to fill critical gaps,
such as seeking help from staffing
agencies, sharing staff between
other local providers, and using
emergency waivers to hire nurse
aides who had yet to complete their
certification. As of January 2021,
we continued to hear that staff are
exhausted, face burn-out from
emotional trauma, need to
quarantine due to exposure to or
illness from the virus, or stay
home to take care of family
members--all of which further
strains staffing resources.
------------------------------------------------------------------------
Personal According to our reviews of data Challenge has
Protective from the CDC and interviews with generally shown
Equipment advocacy organization and national improvement
(PPE) association officials from July
2020 to January 2021, shortages of
PPE in nursing homes have improved
since the beginning of the COVID-19
pandemic but remain an issue:
CDC data show that, as recently as
December 2020, about 10 percent of
nursing homes did not have a one-
week supply of at least one of the
following: N95 respirators,
surgical masks, gloves, eye
protection, or gowns (a decrease
from about 22 percent of nursing
homes in July 2020).
In interviews with advocacy
organizations and national
association officials from July
2020 to January 2021, we heard
that, while challenges maintaining
PPE supplies in reserve is an
ongoing concern, supply shortages
have become less severe over time.
------------------------------------------------------------------------
Testing According to our reviews of CDC data Challenge has
and interviews with a researcher generally shown
and with nursing home association improvement
officials in November 2020 and
January 2021, nursing homes'
ability to use testing to identify
infected residents and staff
through testing protocols has
improved over the course of the
pandemic, but at a high cost to
nursing homes:
Nursing homes have reported to CDC
improved testing capacity.
Specifically, the number of nursing
homes testing for COVID-19 in both
staff and residents has increased
by 48 percentage points--from 35 to
83 percent--between August 16,
2020, and November 22, 2020, the
last week complete data for overall
testing were available.
Although data reported in December
2020 by nursing homes found that
less than 2 percent of nursing
homes would be unable to test all
staff or residents within the week
if needed, nursing home association
officials note that the high cost
of continuous testing is not
sustainable indefinitely.
------------------------------------------------------------------------
Vaccinations According to our reviews of a CDC Emerging challenge
analysis of vaccination data and
interviews with nursing home and
State and local government
officials, nursing homes face some
emerging challenges related to
vaccinations:
A February 2021 CDC study
estimated low rates of vaccine
uptake among nursing home staff (38
percent) compared to nursing home
residents (78 percent)
participating in the Pharmacy
Partnership for Long-Term Care
Program.b
In interviews with nursing home
and State and local government
association officials since the
vaccines were first administered in
December 2020, we heard about
reluctance among some nursing home
staff to receive the COVID-19
vaccine, in addition to hearing
about uncertainty around certain
aspects of vaccination distribution
and requirements earlier in the
year.
------------------------------------------------------------------------
Source: GAO review of CDC data and interviews. | GAO-21-402T
a According to CDC's data documentation, other support staff may include
certified nursing assistants, medication aides, and medication
technicians as reported to CDC by the provider.
b R. Gharpure, et al., ``Early COVID-19 First-Dose Vaccination Coverage
Among Residents and Staff Members of Skilled Nursing Facilities
Participating in the Pharmacy Partnership for Long-Term Care Program--
United States, December 2020-January 2021,'' Centers for Disease
Control and Prevention Morbidity and Mortality Weekly Report, vol. 70,
no. 5 (2021): 178-182.
hhs has taken steps in response to covid-19, but several relevant
gao recommendations have not been implemented
Our prior CARES Act reports have described how HHS, primarily
through CMS and CDC, has taken a series of actions to address COVID-19
in nursing homes, such as providing guidance to nursing homes on
infection control practices and issuing waivers and regulatory
flexibilities.\9\ Examples of other actions include:
---------------------------------------------------------------------------
\9\ For example, in March 2020 CMS waived the requirement that a
nursing home not employ nurse aides for more than 4 months unless they
meet certain training and certification requirements. This was done to
address potential staffing shortages in nursing homes due to the COVID-
19 pandemic.
Temporarily suspending State survey agencies' standard surveys
and many complaint investigations, instead shifting to targeted
infection prevention and control surveys and high-priority complaint
investigations.\10\
---------------------------------------------------------------------------
\10\ On June 1st, CMS issued survey re-prioritization guidance as
part of its nursing home reopening strategy. Specifically, once a State
enters phase 3--a threshold based on factors including case status in
the community and the nursing home, as well as access to testing, PPE,
and adequate staffing--state survey agencies were authorized to expand
beyond conducting targeted infection control surveys and high-priority
complaint investigations to include lower-priority complaint
investigations. See Centers for Medicare and Medicaid Services,
``COVID-19 Survey Activities, CARES Act Funding, Enhanced Enforcement
for Infection Control Deficiencies, and Quality Improvement Activities
in Nursing Homes,'' QSO-20-31-ALL (Baltimore, MD.: June 1, 2020). On
August 17, CMS revised this guidance to authorize traditional,
comprehensive, standard surveys and lower-priority complaint
investigations as soon as State survey agencies have the resources,
such as staff and PPE. See Centers for Medicare and Medicaid Services,
``Enforcement Cases Held During the Prioritization Period and Revised
Survey Prioritization,'' QSO-20-35-ALL (Baltimore, MD.: August 17,
2020).
Creating a new reporting requirement for nursing homes to report
weekly COVID-19 cases and deaths for residents and staff as of May 8,
---------------------------------------------------------------------------
2020.
Distributing antigen diagnostic tests and associated point-of-
care testing instruments to nursing homes.
Distributing billions of dollars in payments from the Provider
Relief Fund, established with funds provided under the CARES Act and
other COVID-19 relief laws, as direct payments to assist nursing homes
with responding to COVID-19.\11\
---------------------------------------------------------------------------
\11\ As of January 15, 2021, $5 billion in Provider Relief Funds
had been allocated for nursing homes and $4.764 billion had been
disbursed.
Convening the Coronavirus Commission on Safety and Quality in
Nursing Homes (the Nursing Home Commission) in June 2020, which was
tasked with assessing the response to the COVID-19 pandemic in nursing
---------------------------------------------------------------------------
homes and made recommendations for additional actions CMS could take.
Establishing the Pharmacy Partnership for Long-Term Care Program
in October 2020, an agreement with CVS, Walgreens, and Managed Health
Care Associates Inc. to provide and administer COVID-19 vaccines to
residents of long-term care facilities, including nursing homes.
Directing nursing homes to expand resident visitation beginning
in March 2021, after previously restricting visitors and non-essential
health care personnel in nursing homes, except in certain compassionate
care situations, to reduce the transmission of COVID-19.\12\
---------------------------------------------------------------------------
\12\ CMS restricted visitors and non-essential health care
personnel in nursing homes from March through September 2020. In
September 2020, CMS issued guidance that allowed for nursing homes to
resume visitations depending on certain factors.
However, HHS has not implemented several of our recommendations
that could help the agency address some of the challenges nursing homes
have faced and fill important voids in the Federal Government's
understanding of, and transparency around, data on COVID-19 in nursing
homes. (See app. I for a description of related GAO reports and the
---------------------------------------------------------------------------
status of their recommendations.)
HHS has not implemented our recommendation related to the
Nursing Home Commission report. CMS released the Nursing Home
Commission's final report in September 2020, which includes 27
recommendations organized under 10 themes--such as Testing and
Screening, Equipment and PPE, Workforce (staffing), and Visitation--
that are paired with over 100 specific action steps for CMS.\13\ CMS
released a response to the report broadly outlining the actions the
agency has taken to date as part of its response to the COVID-19
pandemic, but the agency did not provide an implementation plan that
would allow it to track and report progress toward the Commission's
recommendations.
---------------------------------------------------------------------------
\13\ MITRE, Coronavirus Commission on Safety and Quality in Nursing
Homes: Commission Final Report, PRS Release Number 20-2382, September
2020.
We recommended in November 2020 that the Administrator of CMS
quickly develop a plan that further details how the agency intends to
respond to and implement, as appropriate, the 27 recommendations in the
final report of the Coronavirus Commission on Safety and Quality in
Nursing Homes. HHS neither agreed nor disagreed with our
recommendation; instead, it highlighted actions CMS has taken related
to Commission recommendations and indicated that it would refer to and
act upon the Nursing Home Commission's recommendations as appropriate.
---------------------------------------------------------------------------
CMS reiterated this position in February 2021.
HHS has not implemented our recommendation to fill COVID-19 data
voids. HHS, through CMS, implemented a COVID-19 reporting requirement
for nursing homes effective May 8, 2020 (noted briefly above).\14\ CMS
made the reporting of the data prior to May 8, 2020, optional. As a
result, CMS's data do not capture the early months of the pandemic.\15\
---------------------------------------------------------------------------
\14\ 85 Fed. Reg. 27,550, 27,627 (May 8, 2020) (to be codified at
42 CFR Sec. 483.80(g)). CMS is responsible for ensuring that nursing
homes meet Federal quality standards to participate in the Medicare and
Medicaid programs.
\15\ Nursing homes are required to self-report data regarding
COVID-19 cases and deaths among residents and staff, PPE supplies, and
staffing shortages, among other things, at least weekly through CDC's
National Healthcare Safety Network.
We recommended in September 2020 that the Secretary of HHS, in
consultation with CMS and CDC, develop a strategy to capture more
complete data on confirmed COVID-19 cases and deaths in nursing homes
retroactively back to January 1, 2020, and clarify the extent to which
nursing homes had reported data before May 8, 2020.\16\ Although HHS
partially agreed with this recommendation and indicated that it
continues to consider how to implement this recommendation, the agency
had taken no specific actions, as of February 2021.
---------------------------------------------------------------------------
\16\ Also in September 2020, GAO identified gaps in COVID-19 data
for racial and ethnic minority groups, and, among other things,
recommended that CDC take steps to help ensure its ability to
comprehensively assess the long-term health outcomes of persons with
COVID-19, including by race and ethnicity. HHS agreed with the
recommendation and as of February 2021, CDC is reviewing the quality of
the demographic data and assessing potential opportunities to enhance
the collection of race and ethnicity data.
We maintain the importance of our recommendations. Specifically, we
maintain that developing a plan for whether CMS will proceed with the
Nursing Home Commission's recommendations and, if so, how it will do so
would improve the agency's ability to systematically consider the
Nursing Home Commission's recommendations going forward. We also
maintain that collecting data on COVID-19 cases and deaths from nursing
homes retroactively would better inform the government's continued
response to, and recovery from, the COVID-19 pandemic, and we maintain
that HHS could ease the burden by incorporating data previously
---------------------------------------------------------------------------
reported to CDC or to State or local public health offices.
We also have recommendations from work completed prior to the
pandemic that have yet to be fully implemented by CMS. Implementation
of these recommendations could improve HHS's oversight of nursing homes
both generally and during a pandemic. For example, in our 2019 report
on abuse in nursing homes, we made six recommendations, including
recommending that CMS require State survey agencies to immediately
notify law enforcement of any reasonable suspicion of a crime against a
resident, and that CMS provide more guidance to State survey agencies
on the information nursing homes should include on facility-reported
incidents. CMS agreed with our recommendations.\17\ These
recommendations have relevance prior to, during, and after the COVID-19
pandemic, because with reduced visitors or ombudsmen presence in
nursing homes, and with the decrease or elimination of surveyor
presence, there may be a higher risk of residents being abused and of
that abuse going unreported.\18\ This risk is higher than it needs to
be because CMS has not yet implemented our relevant recommendations.
---------------------------------------------------------------------------
\17\ See GAO, Nursing Homes: Improved Oversight Needed to Better
Protect Residents From Abuse, GAO-19-433 (Washington, DC: June 13,
2019).
\18\ State surveyors evaluate nursing homes' compliance with
Federal quality standards.
In addition to monitoring HHS's implementation of past
recommendations, we have ongoing work examining COVID-19 outbreaks in
nursing homes, as well as CMS's oversight of infection prevention and
control protocols and the adequacy of emergency preparedness standards
---------------------------------------------------------------------------
for emerging infectious diseases in nursing homes.
In summary, the COVID-19 pandemic has underscored the importance of
issues we have previously raised about nursing home quality and
oversight while pointing to new vulnerabilities unique to the pandemic.
Effective Federal oversight and support for nursing homes are
especially critical during times of widespread disease outbreak, as the
pandemic has demonstrated. As nursing homes are prioritized for
vaccination, there is hope that COVID-19 cases and deaths in these
homes will continue to decline. Going forward, our work on COVID-19 in
nursing homes remains important for informing future pandemic
responses, as well as for addressing longer-standing challenges that
have put residents' health and safety at risk, as indicated by our
prior recommendations.
Chairman Wyden, Ranking Member Crapo, and members of the committee,
this concludes my prepared statement. I would be pleased to respond to
any questions that you may have at this time.
appendix i: description of selected gao reports
on nursing homes with recommendations
The following table summarizes the status of relevant
recommendations from GAO's prior reports on nursing home oversight with
the status as of the most recent detailed update. According to the
Centers for Medicare and Medicaid Services (CMS), as of March 2021,
there are no additional updates on the status of these recommendations,
as the agency's focus has been on responding to the pandemic.
Table 1: Description of Selected GAO Reports on Nursing Homes With
Recommendations, April 2011 Through November 2020
------------------------------------------------------------------------
Date Title Summary of recommendations
------------------------------------------------------------------------
November COVID-19: Urgent GAO made one recommendation related
2020 Actions Needed to to nursing homes that the Centers
Better Ensure an for Medicare and Medicaid Services
Effective Federal (CMS) should quickly develop a plan
Response that further details how the agency
(GAO-21-191) intends to respond to and
implement, as appropriate, the 27
recommendations in the final report
of the Coronavirus Commission on
Safety and Quality in Nursing
Homes, which CMS released on
September 16, 2020. The Department
of Health and Human Services (HHS)
neither agreed nor disagreed with
our recommendation and, as of
February 2021, HHS/CMS had not
implemented this recommendation.
------------------------------------------------------------------------
September COVID-19: Federal GAO made one recommendation related
2020 Efforts Could Be to nursing homes that HHS, in
Strengthened by consultation with CMS and the
Timely and Centers for Disease Control and
Concerted Actions Prevention (CDC), develop a
(GAO-20-701) strategy to capture more complete
data on confirmed COVID-19 cases
and deaths in nursing homes
retroactively to January 1, 2020,
in order to address gaps in the new
reporting requirements on COVID-19
cases and deaths in nursing homes.
HHS partially agreed with this
recommendation and, as of February
2021, HHS had not implemented this
recommendation.
------------------------------------------------------------------------
June 2019 Nursing Homes: GAO made six recommendations,
Improved Oversight including that CMS require State
Needed to Better survey agencies to immediately
Protect Residents notify law enforcement of any
from Abuse reasonable suspicion of a crime
(GAO-19-433) against a resident, and that CMS
provide more guidance to State
survey agencies on the information
nursing homes should include on
facility-reported incidents. HHS
agreed with the recommendations
and, as of February 2020, HHS had
not implemented these
recommendations.
------------------------------------------------------------------------
April 2019 Management Report: GAO made three recommendations,
CMS Needs to including that CMS ensure all State
Address Gaps in survey agencies are meeting Federal
Federal Oversight requirements for investigating
of Nursing Home alleged abuse, and that the results
Abuse are shared with CMS. HHS agreed
Investigations That with the recommendations and, as of
Persisted in Oregon November 2019, HHS had implemented
for at Least 15 one of the three recommendations.
Years
(GAO-19-313R)
------------------------------------------------------------------------
November Nursing Homes: GAO made four recommendations,
2016 Consumers Could including that CMS should add
Benefit from information to the Five-Star System
Improvements to the that allows consumers to compare
Nursing Home nursing homes nationally. HHS
Compare Website and agreed with three of the four
Five-Star Quality recommendations and, as of July
Rating System 2019, HHS had implemented three of
(GAO-17-61) the four recommendations.
------------------------------------------------------------------------
October 2015 Nursing Home GAO made three recommendations,
Quality: CMS Should including that CMS implement a
Continue to Improve clear plan for ongoing auditing of
Data and Oversight self-reported data and establish a
(GAO-16-33) process for monitoring oversight
modifications to better assess
their effects. HHS agreed with
GAO's recommendations. As of 2020,
HHS had implemented these three
recommendations.
------------------------------------------------------------------------
April 2011 Nursing Homes: More GAO made seven recommendations aimed
Reliable Data and at ensuring CMS's complaints
Consistent Guidance database is reliable, strengthening
Would Improve CMS CMS's assessment of State survey
Oversight of State agencies' performance in managing
Complaint complaints, and increasing
Investigations accountability for managing the
(GAO-11-280) complaints process. HHS generally
agreed with our recommendations. As
of October 2019, HHS had
implemented two of these seven
recommendations and indicated it
would not be taking action on a
third (GAO closed this as not
implemented).
------------------------------------------------------------------------
Source: GAO. | GAO-21-402T
Note: The hyperlinks to these reports provide additional details about
the recommendations and their statuses.
appendix ii: related gao reports
CARES Act Reports
COVID-19: Critical Vaccine Distribution, Supply Chain, Program
Integrity, and Other Challenges Require Focused Federal Attention. GAO-
21-265. Washington, DC: January 28, 2021.
COVID-19: Urgent Actions Needed to Better Ensure an Effective Federal
Response. GAO-21-191. Washington, DC: November 30, 2020.
COVID-19: Federal Efforts Could Be Strengthened by Timely and Concerted
Actions. GAO-20-701. Washington, DC: September 21, 2020.
COVID-19: Opportunities to Improve Federal Response and Recovery
Efforts. GAO-20-625. Washington, DC: June 25, 2020.
Other GAO Reports
Infection Control Deficiencies Were Widespread and Persistent in
Nursing Homes Prior to COVID-19 Pandemic. GAO-20-576R. Washington, DC:
May 20, 2020.
Elder Abuse: Federal Requirements for Oversight in Nursing Homes and
Assisted Living Facilities Differ. GAO-19-599. Washington, DC: August
19, 2019.
Nursing Homes: Improved Oversight Needed to Better Protect Residents
from Abuse. GAO-19-433. Washington, DC: June 13, 2019.
Management Report: CMS Needs to Address Gaps in Federal Oversight of
Nursing Home Abuse Investigations That Persisted in Oregon for at Least
15 Years. GAO-19-313R. Washington, DC: April 15, 2019.
Nursing Homes: Consumers Could Benefit from Improvements to the Nursing
Home Compare Website and Five-Star Quality Rating System. GAO-17-61.
Washington, DC: November 18, 2016.
Nursing Home Quality: CMS Should Continue to Improve Data and
Oversight. GAO-16-33. Washington, DC: October 30, 2015.
Antipsychotic Drug Use: HHS Has Initiatives to Reduce Use Among Older
Adults in Nursing Homes, but Should Expand Efforts to Other Settings.
GAO-15-211. Washington, DC: January 30, 2015.
Nursing Homes: More Reliable Data and Consistent Guidance Would Improve
CMS Oversight of State Complaint Investigations. GAO-11-280.
Washington, DC: April 7, 2011.
______
Questions Submitted for the Record to John E. Dicken
Questions Submitted by Hon. Ron Wyden
Question. What changes do you recommend to the Five-Star system so
it will better reflect patients' outcomes of care and inform residents
and loved ones about the quality and safety of nursing homes?
Answer. We last reported on the Five-Star Quality Rating System
(Five-Star System) in November 2016 (see GAO-17-61). We made four
recommendations in that report, three of which have been implemented by
the Centers for Medicare and Medicaid Services (CMS) and one of which
remains unimplemented.
With regard to the unimplemented recommendation, we recommended
that, to help improve the Five-Star System's ability to enable
consumers to understand nursing home quality and make distinctions
between high- and low-performing homes, the Administrator of CMS should
add information to the Five-Star System that allows consumers to
compare nursing homes nationally. The Department of Health and Human
Services (HHS) did not concur with this recommendation. In July 2019,
CMS officials told us they do not plan to implement this
recommendation, and as of March 2021 CMS had not informed us of steps
taken to address the recommendation. However, we maintain that adding
national comparison information is important, especially for those
consumers who live near State borders or have multi-State options.
We also recommended in that report that CMS evaluate the
feasibility of adding consumer satisfaction information to the Five-
Star System. HHS concurred with this recommendation and provided us
with such a study dated October 2017, leading us to close the
recommendation as implemented. However, the study described
``widespread consensus that measuring satisfaction of nursing home
residents and families is crucial to understanding resident experience
and to informing consumers on choosing a nursing home.'' This suggests
that CMS could better inform residents and their loved ones about the
quality and safety of nursing homes by taking the next step of adding
consumer satisfaction information to the Five-Star System.
As GAO continues to evaluate the federal response to COVID-19 in
nursing homes and the effects of the pandemic on the safety and welfare
of nursing home residents, we will also monitor challenges the pandemic
will pose for CMS's Five-Star System going forward. For example,
nursing home inspection results are one key element of the Five-Star
System's ratings, but many standard inspections have not occurred or
have been delayed during this national emergency, consistent with CMS's
guidelines. Thus, the information consumers receive from the Five-Star
System will be a less timely and accurate representation of care
provided during the pandemic.
Question. The involvement of private equity in the nursing home
industry has been of interest to the Finance Committee for more than a
decade, and the role of private equity and for profit ownership in the
nursing home industry was raised in testimony and questions at the
hearing. The Government Accountability Office (GAO) considered this
issue in a 2010 report, ``Nursing Homes: Complexity of Private
Investment Purchases Demonstrates Need for CMS to Improve the Usability
and Completeness of Ownership Data.'' Please provide an update on the
status of the recommendations made in this report.
Answer. The 11 recommendations from that report, GAO-10-710, are
closed. Five were closed as implemented, and six were closed as not
implemented. The recommendations not implemented are summarized in the
following paragraphs, but full details are available in the report and
on the GAO website.
Three of the recommendations not implemented relate to the Patient
Protection and Affordable Care Act (PPACA), which expanded the
ownership and control reporting requirements for Medicare and Medicaid
nursing homes. At the time we reported, these PPACA requirements had
not yet been implemented, and we recommended that HHS consider
requiring certain types of reporting as it developed the regulations to
implement these requirements. For each of these recommendations, CMS
told GAO that it had taken steps to obtain the recommended information
by making changes to its provider enrollment application form. However,
in each case GAO assessed that the changes did not specifically or
sufficiently address the information targeted by our recommendations.
Because CMS had not indicated any plans to take further actions at the
time these recommendations were closed, GAO considered them to be
closed and not implemented.
The other three recommendations not implemented related to
information HHS should require nursing homes to report or to actions
HHS should take to ensure the usability, accuracy, and completeness of
nursing home ownership information. In the case of our recommending an
additional reporting requirement, CMS told GAO that, upon further
review, it had determined that taking action would represent an undue
burden on providers, given the existing functionality of its provider
enrollment system, and that the agency considered the matter closed. In
the other two cases, CMS told GAO about actions it had taken related to
the recommendations and said that the agency had no further updates and
considered the matters closed.
GAO currently has ongoing work related to the quality of nursing
homes with chain ownership, including private equity owners, which
should provide more up-to-date information on this topic.
Question. During the hearing, several Senators and witnesses raised
the importance of the Federal Government collecting and publishing
information from individual nursing homes that show the rate of
vaccinations for residents and staff. Since that time, a bipartisan
group of senators have sent a letter to the U.S. Department of Health
and Human Services calling on it to take steps to begin this data
collection. Has GAO issued any recommendations in relation to this
issue?
Answer. The Federal Government's collection and reporting of
nursing home vaccination data is important for providing insight into
nursing home quality of care and protecting the vulnerable nursing home
population. We made two recommendations related to this issue in our
March 2021 CARES Act report (see GAO-21-387).
First, we recommended that the Secretary of HHS should ensure that
the Director of the CDC collects data specific to the COVID-19
vaccination rates in nursing homes and makes these data publicly
available to better ensure transparency and that the necessary
information is available to improve ongoing and future vaccination
efforts for nursing home residents and staff. HHS neither agreed nor
disagreed with this recommendation.
In response to our recommendation, HHS said it is working towards
better data transparency and noted that nursing homes have an
opportunity to voluntarily report data through the National Healthcare
Safety Network (NHSN) tracking system. However, according to CDC, as of
February 17, 2021, around 14 percent of nursing homes are voluntarily
reporting staff vaccination data through NHSN and around 18 percent are
voluntarily reporting resident vaccination data. We maintain that more
complete data on COVID-19 vaccinations in nursing homes will be
important for CMS's ongoing efforts to monitor nursing home quality and
that making these data transparent through public reporting provides
consumers with insight into how well nursing homes are caring for their
residents.
Second, we recommended that the Secretary of HHS should ensure that
the Administrator of CMS, in consultation with CDC, requires nursing
homes to offer COVID-19 vaccinations to residents and staff and design
and implement associated quality measures. HHS neither agreed nor
disagreed with this recommendation.
In response to our recommendation, HHS indicated that CMS is
``actively evaluating'' whether changes need to be made to its
infection control requirements regarding the COVID-19 vaccine and that
CMS and CDC ``have made progress in developing quality measures related
to COVID-19 vaccination.'' We note that CMS already requires nursing
homes to offer influenza and pneumococcal vaccinations to nursing home
residents; given the significant threat COVID-19 poses to nursing home
residents, with a mortality rate far exceeding that of influenza, we
maintain the importance of this recommendation for protecting the
vulnerable nursing home population.
On April 8, 2021, CMS published a proposed rule that, among other
things, proposes the adoption of a ``COVID-19 Vaccination Coverage
among Healthcare Personnel'' quality measure. This would require
Skilled Nursing Facilities (SNF) to report on COVID-19 vaccination of
staff. Under the proposal, SNFs would begin reporting vaccination data
through CDC's NHSN beginning October 1, 2021, and the quality measure
would be adopted beginning in fiscal year 2023. We will continue to
monitor CMS's actions responding to these two recommendations.
Question. The South African and Brazilian variants continue to
circulate in the United States. What are issues Congress should
consider in regards to the danger that these and other COVID-19
variants may pose to nursing homes, particularly residents who have
been most vulnerable to the disease?
Answer. As we noted in our March 2021 CARES Act report (see GAO-21-
387), the emergence of new COVID-19 variants underscores the need to
remain vigilant in efforts to contain the spread of the virus. For
example, one expert we interviewed noted that different variants could
increase the number of COVID-19 cases and deaths and reduce health care
systems' ability to care for patients. Because nursing home residents
are at high risk for COVID-19 infection and death, due to the virus's
high mortality rate among elderly adults and those with underlying
conditions, continued vigilance is especially important for nursing
homes.
As we reported in the same March 2021 report, several experts told
us that it is important for the federal government to help the public
and stakeholders understand how to use its COVID-19 data, and one
expert specifically highlighted the importance of doing so for data on
COVID-19 variants. While CDC already makes data available on case
numbers for COVID-19 variants, this expert told us that it is also
important for the federal government to explain how to interpret these
numbers and describe how stakeholders, including State and local public
health officials, could use these data to inform their efforts to
respond to the pandemic. This could include how data could be used to
inform response efforts in nursing homes.
Additionally, collecting more complete data on COVID-19
vaccinations in nursing homes, as we recommended in our March 2021
CARES Act report (see previous response), could help with understanding
whether vaccinated residents may be vulnerable to infection by COVID-19
variants. Similarly, demographic data, such as race and ethnicity data,
for COVID-19 in nursing homes could help with understanding whether
COVID-19 variants may have a disproportionate effect on a particular
group. In our September CARES Act report (see GAO-20-701), we made
three recommendations related to the collection of demographic data for
COVID-19, including data on race and ethnicity; these recommendations
remain open.
Question. Is additional surveillance necessary to detect the spread
of viral variants? What types of surveillance, if any, should be
implemented in regards to the nursing home industry specifically?
Answer. Surveillance is important for understanding the
transmission of the virus, including variants. More complete data on
COVID-19 in nursing homes, including data on COVID-19 vaccinations and
demographic data, may help with understanding the impact of COVID-19
variants on nursing home residents. CMS and CDC could begin to gather
more complete data on COVID-19 in nursing homes by implementing our
recommendations.
Question. In the event that additional vaccinations and/or booster
shots are needed to protect against variants, what lessons can be drawn
from the experience of the CVS Walgreen Long-Term Care Partnership?
Answer. While we have not done a full evaluation of the Pharmacy
Partnership for Long-Term Care Program, we noted in our March 2021
CARES Act report (see GAO-21-387) that a key challenge was the
decentralization of the partnership program. Originally designed to be
a federal program, each State was ultimately responsible for activating
the partnership and allocating doses to the partnership. According to
State and nursing home association officials, this resulted in more
than 50 different plans for implementation, which caused confusion
among jurisdictions' health departments, nursing homes, and pharmacy
partners and hampered communication and vaccine education efforts. The
officials said a more centralized distribution model may have created a
more efficient approach to vaccinating the nursing home population.
Question. The GAO has issued numerous recommendations related to
nursing homes over the years. Please provide a list of all outstanding
recommendations that relate to the Centers for Medicare and Medicaid
Services and remain open.
Answer. The following recommendations related to nursing homes and
CMS remain open. We maintain that implementing these recommendations
could improve HHS's oversight of nursing homes both generally and
during a pandemic.
1. The Secretary of HHS should ensure that the Administrator of
CMS, in consultation with CDC, requires nursing homes to offer COVID-19
vaccinations to residents and staff and design and implement associated
quality measures.
Source: GAO-21-387, published March 31, 2021.
2. The Administrator of CMS should quickly develop a plan that
further details how the agency intends to respond to and implement, as
appropriate, the 27 recommendations in the final report of the
Coronavirus Commission on Safety and Quality in Nursing Homes, which
CMS released on September 16, 2020. Such a plan should include
milestones that allow the agency to track and report on the status of
each recommendation; identify actions taken and planned, including
areas where the CMS determined not to take action; and identify areas
where the agency could coordinate with other federal and nonfederal
entities.
Source: GAO-21-191, published November 30, 2020.
3. The Secretary of HHS, in consultation with CMS and CDC, should
develop a strategy to capture more complete data on confirmed COVID-19
cases and deaths in nursing homes retroactively back to January 1,
2020, and to clarify the extent to which nursing homes have reported
data before May 8, 2020. To the extent feasible, this strategy to
capture more complete data should incorporate information nursing homes
previously reported to CDC or to State or local public health offices.
Source: GAO-20-701, published September 21, 2020.
4. The administrator of CMS should require that abuse and
perpetrator type be submitted by State survey agencies in CMS's
databases for deficiency, complaint, and facility reported incident
data, and that CMS systematically assess trends in these data.
Source: GAO-19-433, published June 13, 2019.
5. The administrator of CMS should require State survey agencies
to immediately refer complaints and surveys to law enforcement (and,
when applicable, to Medicaid Fraud Control Units) if they have a
reasonable suspicion that a crime against a resident has occurred when
the complaint is received.
Source: GAO-19-433, published June 13, 2019.
6. The administrator of CMS should develop and disseminate
guidance--including a standardized form--to all State survey agencies
on the information nursing homes and covered individuals should include
on facility-reported incidents.
Source: GAO-19-433, published June 13, 2019.
7. The administrator of CMS should conduct oversight of State
survey agencies to ensure referrals of complaints, surveys, and
substantiated incidents with reasonable suspicion of a crime are
referred to law enforcement (and, when applicable, to Medicaid Fraud
Control Units) in a timely fashion.
Source: GAO-19-433, published June 13, 2019.
8. The administrator of CMS should develop guidance for State
survey agencies clarifying that allegations verified by evidence should
be substantiated and reported to law enforcement and State registries
in cases where citing a federal deficiency may not be appropriate.
Source: GAO-19-433, published June 13, 2019.
9. The administrator of CMS should provide guidance on what
information should be contained in the referral of abuse allegations to
law enforcement.
Source: GAO-19-433, published June 13, 2019.
10. CMS should evaluate State survey agency processes in all
States to ensure all State survey agencies are meeting federal
requirements that State survey agencies are responsible for
investigating complaints and facility-reported incidents alleging abuse
in nursing homes, and that the results of those investigations are
being shared with CMS.
Source: GAO-19-313R, published April 15, 2019.
11. CMS should identify options for capturing information from
Oregon's Adult Protective Services investigations of complaints and
facility-reported incidents of abuse and incorporate this information
into oversight of Oregon nursing homes.
Source: GAO-19-313R, published April 15, 2019.
12. To help improve the Five-Star System's ability to enable
consumers to understand nursing home quality and make distinctions
between high- and low- performing homes, the Administrator of CMS
should add information to the Five-Star System that allows consumers to
compare nursing homes nationally.
Source: GAO-17-61, published November 18, 2016.
13. To improve the accessibility and reliability of SNF
expenditure data, the Acting Administrator of CMS should take steps to
improve the accessibility of SNF expenditure data, making it easier for
public stakeholders to locate and use the data.
Source: GAO-16-700, published September 7, 2016.
14. To improve the accessibility and reliability of SNF
expenditure data, the Acting Administrator of CMS should take steps to
ensure the accuracy and completeness of SNF expenditure data.
Source: GAO-16-700, published September 7, 2016.
15. To improve consumers' access to relevant and understandable
information on the cost and quality of health care services, the
Secretary of HHS should direct the Administrator of CMS to include in
the CMS Compare websites, to the extent feasible, estimated out-of-
pocket costs for Medicare beneficiaries for common treatments that can
be planned in advance.
Source: GAO-15-11, published October 20, 2014.
16. To improve consumers' access to relevant and understandable
information on the cost and quality of health care services, the
Secretary of HHS should direct the Administrator of CMS to organize
cost and quality information in the CMS Compare websites to facilitate
consumer identification of the highest-performing providers, such as by
listing providers in order based on their performance.
Source: GAO-15-11, published October 20, 2014.
17. To improve consumers' access to relevant and understandable
information on the cost and quality of health-care services, the
Secretary of HHS should direct the Administrator of CMS to include in
the CMS Compare websites the capability for consumers to customize the
information presented, to better focus on information relevant to them.
Source: GAO-15-11, published October 20, 2014.
18. To improve consumers' access to relevant and understandable
information on the cost and quality of health-care services, the
Secretary of HHS should direct the Administrator of CMS to develop
specific procedures and performance metrics to ensure that CMS's
efforts to promote the development and use of its own and others'
transparency tools adequately address the needs of consumers.
Source: GAO-15-11, published October 20, 2014.
19. To ensure that information entered into CMS's complaints
database is reliable and consistent, the Administrator of CMS should
identify issues with data quality and clarify guidance to States about
how particular fields in the database should be interpreted, such as
what it means to substantiate a complaint.
Source: GAO-11-280, published April 7, 2011.
20. To strengthen CMS's assessment of State survey agencies'
performance in the management of nursing home complaints , the
Administrator of CMS should conduct additional monitoring of State
performance using information from CMS's complaints database, such as
additional timeliness measures.
Source: GAO-11-280, published April 7, 2011.
21. To strengthen and increase accountability of State survey
agencies' management of the nursing home complaints process, the
Administrator of CMS should clarify guidance to the State survey
agencies about the minimum information that should be conveyed to
complainants at the close of an investigation.
Source: GAO-11-280, published April 7, 2011.
22. To strengthen and increase accountability of State survey
agencies' management of the nursing home complaints process, the
Administrator of CMS should provide guidance encouraging State survey
agencies to prioritize complaints at the level that is warranted, not
above that level.
Source: GAO-11-280, published April 7, 2011.
______
Questions Submitted by Hon. Elizabeth Warren
Question. Please provide a full list of all GAO recommendations
related to CMS's Provider Enrollment, Chain, and Ownership System
(PECOS) that the agency has yet to complete and identify which
recommendations have not been implemented by CMS or other relevant
regulators.
Answer. GAO does not currently have any open recommendations
targeted to CMS's Provider Enrollment, Chain, and Ownership System
(PECOS). However, we have made recommendations targeted to PECOS in the
past, several of which were closed as implemented (see, for example,
GAO-15-448). At least one recommendation targeted to PECOS--from our
2010 report on private investment in nursing homes, GAO-10-710--was
closed as not implemented:
1. To improve the usability and accuracy of the ownership and
control information collected and stored in PECOS, the Administrator of
CMS should examine State systems to identify best practices for the
collection and public dissemination of nursing home ownership and chain
information, including ways in which States make the hierarchy among
owners more apparent.
In 2012, CMS told GAO that it had recently implemented an
automated provider screening system and that it was continuing to have
internal discussions and explore data sources that can provide nursing
home information for that system. However, CMS said it had no further
updates and that it considered the matter closed.
Question. What recommendations, if any, does GAO have for the
executive branch to improve its visibility into the ownership of
private-equity-owned nursing homes?
Answer. GAO does not have any open recommendations related to
private-equity-owned nursing homes. However, GAO currently has ongoing
work related to the quality of nursing homes with chain ownership,
including private equity owners.
Question. GAO has analyzed nursing homes through the lens of the
COVID-19 pandemic and provided Congress with a series of
recommendations. Are any of GAO's COVID-19-related recommendations
specifically targeted at or relevant for for-profit facilities,
including private-equity-owned facilities? Did the COVID-19 pandemic
reveal any differences in the ability of for- and non-profit facilities
to provide high-quality care to residents or to protect them from
pandemics?
Answer. None of the four COVID-19-related nursing homes
recommendations from our CARES Act reporting are specifically targeted
to for-profit facilities; however, each of the four recommendations is
relevant to all nursing homes, which would include for-profit
facilities (see Lankford question, later in this response, for a list
of these recommendations).
GAO currently has ongoing work looking at which nursing home
characteristics, if any, affect the likelihood that a home experienced
a COVID-19 outbreak. We are also aware of ongoing work from the HHS
Office of Inspector General (OIG) that will describe the
characteristics of the nursing homes that were hardest hit by the
pandemic (OEI-02-20-00490).
Additionally, although not specific to the COVID-19 pandemic, we
have previously reported on the intersection of nursing home
characteristics and nursing home quality:
In May 2020, we reported that, over a 5-year period, while
nursing homes owned by for-profit organizations comprised about 68
percent of all surveyed nursing homes, they accounted for 72 percent of
nursing homes that had infection prevention and control deficiencies
cited in multiple years but only about 61 percent of nursing homes with
no infection prevention and control deficiencies cited (see GAO-20-
576R).
In 2015, we reported that the poorest performing nursing
homes were more likely to be for-profit or large homes (greater than
100 beds) compared to homes that performed well; this was consistent
with a 2009 GAO analysis on the most poorly performing nursing homes
(see GAO-16-33, GAO-09-689).
In 2011, we reported that private investment and other for-
profit nursing homes had more total deficiencies than nonprofit homes,
both before and after acquisition by private investment firms (see GAO-
11-571).
______
Questions Submitted by Hon. John Barrasso
Question. Through the years, nursing homes in my State have
reported they have lost the ability to train their own CNAs. According
to an article published in Health Affairs, this is because nursing
homes with a civil monetary penalty greater than $10,000 lose the
ability to conduct CNA training for 2 years. In rural communities,
where the nursing home is often the sole source of training for CNAs,
this creates a tremendous burden. Please comment on the impact losing
the ability to train CNAs has on nursing homes.
Answer. GAO does not currently have any ongoing work or open
recommendations focused on CNA training, including in rural
communities, but, if you would like, we would be happy to follow up
with your staff to further discuss this issue.
We note that the Coronavirus Commission on Safety and Quality in
Nursing Homes--which we refer to as the Nursing Home Commission and
which was appointed by CMS--reported that the COVID-19 pandemic has
disrupted CNA training, ``leading to serious CNA workforce deficits.''
The Nursing Home Commission recommended that CMS catalyze interest in
the CNA profession through diverse recruitment vehicles; issue guidance
for on-the-job CNA training, testing, and certification; and create a
national CNA registry.\1\
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\1\ MITRE, Coronavirus Commission on Safety and Quality in Nursing
Homes: Commission Final Report, PRS Release Number 20-2382, September
2020.
In our November 2020 CARES Act report (see GAO-21-191), we
recommended that the Administrator of CMS quickly develop a plan that
further details how the agency intends to respond to and implement, as
appropriate, the 27 recommendations in the final report of the Nursing
Home Commission. As of February 2021, this recommendation had not been
implemented. However, we maintain the importance of this
recommendation, as developing a plan for whether CMS will proceed with
the Nursing Home Commission 's recommendations--and, if so, how it will
do so--would improve the agency's ability to systematically consider
the recommendations going forward, to include the recommendation
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related to CNAs.
Question. Can you provide suggestions on how to address this
situation, especially in rural communities?
Answer. See previous response.
Question. Please discuss the impact of staffing turnover on the
quality of care provided in nursing homes.
Answer. GAO has ongoing related work examining the relationship
between staffing levels and the rate of critical incidents at skilled
nursing facilities prior to the pandemic. If you would like, we would
be happy to follow up with your staff to further discuss this issue.
Question. Specifically, do you believe turnover rates from nursing
homes should be made more readily available for public review?
Answer. GAO does not have any recommendations on this issue.
However, we are aware that the HHS OIG recently made a related
recommendation. In March 2021, HHS OIG reported that federal law
requires CMS to provide data on staffing turnover and tenure on Care
Compare, but that CMS has not yet done so. CMS told HHS OIG that the
agency was delayed by the COVID-19 pandemic. HHS OIG recommended that
CMS provide data to consumers on nurse staff turnover and tenure, as
required by federal law.\2\
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\2\ Department of Health and Human Services, Office of Inspector
General, CMS Use of Data on Nursing Home Staffing: Progress and
Opportunities To Do More, OEI-04-18-00451 (Washington, DC: March 2021).
______
Questions Submitted by Hon. Todd Young
Question. What are some lessons learned from the public health
emergency in terms of the integration of technology in nursing homes-
both in helping residents visit virtually with loved ones and in
accessing health care services?
Answer. GAO currently has ongoing work that may address the use of
technology in nursing homes for telehealth and other purposes.
For example, as part of our ongoing work examining nursing home
challenges associated with the COVID-19 pandemic, we have interviewed
officials from three State long-term care ombudsman programs, some of
whom have utilized or plan to utilize technology to connect with
residents during the pandemic.
Additionally, we have ongoing work examining the use of telehealth
in Medicare and Medicaid. This includes HHS's use of statutory and
regulatory flexibilities to temporarily waive or modify Medicare
telehealth provisions in response to COVID-19, as well as how States
have used telehealth in Medicaid to respond to the pandemic. While this
work is focused on Medicare and Medicaid broadly, it is also relevant
to nursing homes specifically, because these waivers permit telehealth
visits in nursing homes.
Finally, in our January CARES Act report (see GAO-21-265, Veterans
Health Care enclosure), we discussed the Department of Veterans
Affairs' (VA) use of telehealth. Again, while not specific to nursing
homes, this work is relevant because VA provides or pays for nursing
home care in various settings. Among other things, we reported that
VA's Veterans Health Administration (VHA) has several ongoing efforts
aimed at removing technology barriers to telehealth use among veterans;
for example, VHA has directed facilities to establish programs to help
veterans become familiar with telehealth technology.
Question. How do you anticipate this type of technology continuing
to be used beyond the pandemic?
Answer. Our ongoing work on telehealth in Medicare and Medicaid,
mentioned earlier, may address this question. For example, as part of
our ongoing work examining HHS's Medicare telehealth waivers, we plan
to examine the perspectives of beneficiaries, providers, and payers on
Medicare telehealth services and on the idea of making some Medicare
telehealth waivers permanent.
Question. Based on your oversight of CMS's infection prevention
protocols and emergency preparedness standards, what further steps
should the Federal Government take to encourage proper antibiotic
stewardship in nursing homes?
Answer. Last year, we issued a report on additional federal actions
needed to reduce the impact of antibiotic resistant bacteria broadly,
not limited to nursing homes (see GAO-20-341). In that report, we
credited federal agencies for actions already taken to encourage proper
antibiotic stewardship in nursing homes. For example, we noted that CMS
published requirements for nursing homes and skilled nursing facilities
to establish antibiotic stewardship programs by December 4, 2017, which
experts credited as being a powerful lever for promoting the
appropriate use of antibiotics. We also noted that, since 2014, CDC has
published a series of guidance documents called the Core Elements of
Antibiotic Stewardship, which are tailored to nursing homes and other
settings. However, challenges remain, such as in collecting antibiotic
use data from nursing homes, which less commonly use electronic health
record systems that would facilitate data access. The Federal
Government could further encourage proper antibiotic stewardship
generally, including in nursing homes, by implementing that report's
eight recommendations, all of which remain open.
Additionally, the Federal Government could address the one
remaining open recommendation from our 2017 report on Food and Drug
Administration (FDA) efforts to encourage the development of new
antibiotics (see GAO-17-189). Specifically, we recommended that FDA
develop and make available written guidance on the qualified infectious
disease products (QIDP) designation that includes information about the
process a drug sponsor must undertake to request the fast track
designation, and about how the agency is applying the market
exclusivity incentive. As of August 2020, FDA reported that it is
working to finalize draft guidance issued in January 2018 that
describes the QIDP designation.
______
Questions Submitted by Hon. John Cornyn
Question. GAO has noted the challenge of staff shortages that
nursing homes have faced during the pandemic. Reports have noted the
use of staffing agencies, shared staff with other providers, and the
use of emergency waivers to hire nurse aides who have yet to complete
their certification. What steps can be taken to provider greater
flexibility to nursing homes to maintain necessary staff levels without
negatively impacting resident care?
Answer. We note that the Nursing Home Commission, which was
appointed by CMS, made five recommendations (with more than 20
associated action steps) related to stopgap measures to support the
nursing home workforce.\3\ This included actions such as assessing
federal relief funds for hazard pay options and updating interstate
compact language addressing public health emergencies to support a
surge-staffing pool in viral hotspots.
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\3\ MITRE, Commission Final Report, 41-47.
In our November 2020 CARES Act report (see GAO-21-191), we
recommended that the Administrator of CMS quickly develop a plan that
further details how the agency intends to respond to and implement, as
appropriate, the 27 recommendations in the final report of the Nursing
Home Commission. As of February 2021, this recommendation had not been
implemented. However, we maintain the importance of this
recommendation, as developing a plan for whether CMS will proceed with
the Nursing Home Commission's recommendations--and, if so, how it will
do so--would improve the agency's ability to systematically consider
the recommendations going forward, to include the recommendations
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related to stopgap measures to support the nursing home workforce.
Additionally, GAO currently has ongoing work examining the use of
contract staff in nursing homes.
Along similar lines, HHS OIG reported in August 2020 that many
nursing homes were not meeting required staffing levels even prior to
the COVID-19 pandemic. In an analysis of 2018 data, HHS OIG found that
14 percent of nursing homes reported 16 or more days where staffing was
below required levels in 2018; another 40 percent reported between 1
and 15 days where staffing was below required levels.\4\ HHS OIG noted
that in April 2018, CMS announced it would automatically downgrade
nursing homes' Staffing Star Ratings on Nursing Home Compare if they
reported at least 7 total days with no reported registered nurse time
during a quarter; according to OIG, 27 percent fewer nursing homes
reported days with no registered nurse time following this
announcement. However, OIG noted that there were still nursing homes
falling short of meeting staffing requirements in ways not addressed by
this penalty. HHS OIG recommended that CMS enhance its efforts to
ensure nursing homes meet daily staffing requirements, such as by
expanding the agency's use of Payroll Based Journal data to identify
understaffed nursing homes and target them for further oversight.
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\4\ Department of Health and Human Services, Office of Inspector
General, Some Nursing Homes' Reported Staffing Levels in 2018 Raise
Concerns; Consumer Transparency Could Be Increased, OEI-04-18-00450
(Washington, DC: August 2020).
Question. GAO has also noted a reluctance in some nursing home
staff to receive the COVID-19 vaccine. Are there specific
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recommendations to improve address this reluctance?
Answer. In our March CARES Act report (see GAO-21-387), we shared
that State and nursing home association officials had indicated that
COVID-19 vaccine take-up rates among staff were lower than among
residents. They attributed this to several factors, including
underlying issues of government mistrust and myths spread on social
media. However, because CDC does not have complete data on vaccines
administered in nursing homes outside of the Pharmacy Partnership for
Long-Term Care Program, and because CDC publicly reports vaccination
information collected through that program only for all long-term care
facilities (rather than nursing homes specifically), it is unclear how
successful efforts have been to vaccinate nursing home staff.
While GAO does not have specific recommendations to address nursing
home staff reluctance to receive the COVID-19 vaccine, our March
report's recommendations relating to nursing home COVID-19 vaccination
data and associated quality measures could, if implemented, better
ensure that the necessary information is available to improve ongoing
and future vaccination efforts for nursing home staff. Additionally,
they could help ensure that data on staff vaccination rates are
available to help manage the risk of COVID-19 outbreaks in nursing
homes and serve as an important source of information for consumers
about quality of care. We note that, on April 8, 2021, CMS published a
proposed rule related to these recommendations (see previous response
to Wyden Q3) .
______
Questions Submitted by Hon. James Lankford
Question. What, in your opinion, does the nursing home industry
need most to solve some of the problems that are consistently discussed
surrounding nursing home facility underreporting, fraudulent reporting,
and instances of abuse? Would you suggest different staff requirements
and/or enhanced CMS oversight?
Answer. GAO has several recommendations related to reporting (and
underreporting) of abuse and COVID-19 data in nursing homes. By
implementing these recommendations, Federal agencies could improve
their oversight of nursing homes both generally and during a pandemic.
We last reported on instances of abuse in nursing homes in November
2019 (see testimony GAO-20-259T and related report GAO-19-433). We made
six recommendations in GAO-19-433 (see Wyden Q5 earlier in our
response, #4 through 9). CMS agreed with these recommendations, but
they all remain open. The risk of residents being abused, and of that
abuse going unreported, is higher than it needs to be because CMS has
not yet implemented these recommendations.
As we first reported in our September 2020 CARES Act report (see
GAO-20-701), COVID-19 cases and deaths in nursing homes are likely
underreported in CMS and CDC data because, among other reasons, CMS
does not require nursing homes to report data prior to May 8, 2020. As
a result, the data do not provide HHS with a complete picture of the
extent of the pandemic and its effect on nursing homes. To address this
issue, we recommended that the Secretary of HHS--in consultation with
CMS and CDC--develop a strategy to capture more complete data on
confirmed COVID-19 cases and deaths in nursing homes retroactively to
January 1, 2020. As of February 2021, this recommendation had not been
implemented. We maintain that implementing this recommendation could
help fill important gaps in the Federal Government's understanding of,
and transparency around, data on COVID-19 in nursing homes.
Similarly, in our March CARES Act report (see GAO-21-387), we noted
that HHS does not publicly report data showing vaccination rates
specifically for nursing homes and does not have complete vaccination
data for nursing homes not participating in the Pharmacy Partnership
for Long-Term Care Program. As a result, it is unclear to what extent
efforts to vaccinate nursing home residents have been successful, and
it may be difficult to use these data to improve ongoing and future
vaccination efforts for the nursing home population. We made two
recommendations to address this issue:
1. The Secretary of HHS should ensure that the Director of the
CDC collects data specific to the COVID-19 vaccination rates in nursing
homes and makes these data publicly available to better ensure
transparency and that the necessary information is available to improve
ongoing and future vaccination efforts for nursing home residents and
staff.
2. The Secretary of HHS should ensure that the Administrator of
CMS, in consultation with the CDC, requires nursing homes to offer
COVID-19 vaccinations to residents and staff and design and implement
associated quality measures.
We note that, on April 8, 2021, CMS published a proposed rule
related to these recommendations (see previous response to Wyden Q3).
Question. It has been noted that a nursing home's star rating has
little to no correlation to its COVID infection rates. Nursing homes
across the country have been overwhelmingly shut down for the larger
part of the past year. However, about a third of COVID deaths in the
U.S. have been from within largely closed facilities. It is also widely
noted that isolation of nursing home residents had little to do with
infection control, and that the best indicator of COVID in a nursing
home was simply community spread. Mr. Dicken, what are your preliminary
recommendations to protect long-term care residents from nearly the
same impacts of COVID community-spread of those outside a nursing
facility?
Answer. We maintain the importance of our four CARES Act report
recommendations related to nursing homes for improving the Federal
response to COVID-19 in nursing homes and protecting nursing home
residents from the impacts of COVID-19. These recommendations, which
remain open, are:
1. The Secretary of HHS should ensure that the Director of the
CDC collects data specific to the COVID-19 vaccination rates in nursing
homes and makes these data publicly available to better ensure
transparency and that the necessary information is available to improve
ongoing and future vaccination efforts for nursing home residents and
staff.
Source: GAO-21-387, published Mar. 31, 2021.
2. The Secretary of HHS should ensure that the Administrator of
CMS, in consultation with the CDC, requires nursing homes to offer
COVID-19 vaccinations to residents and staff and design and implement
associated quality measures.
Source: GAO-21-387, published Mar. 31, 2021.
3. The Administrator of CMS should quickly develop a plan that
further details how the agency intends to respond to and implement, as
appropriate, the 27 recommendations in the final report of the Nursing
Home Commission, which CMS released on September 16, 2020. Such a plan
should include milestones that allow the agency to track and report on
the status of each recommendation; identify actions taken and planned,
including areas where the CMS determined not to take action; and
identify areas where the agency could coordinate with other Federal and
nonfederal entities.
Source: GAO-21-191, published Nov. 30, 2020.
4. The Secretary of HHS, in consultation with CMS and CDC, should
develop a strategy to capture more complete data on confirmed COVID-19
cases and deaths in nursing homes retroactively back to January 1,
2020, and to clarify the extent to which nursing homes have reported
data before May 8, 2020. To the extent feasible, this strategy to
capture more complete data should incorporate information nursing homes
previously reported to CDC or to State or local public health offices.
Source: GAO-20-701, published Sept. 21, 2020.
Additionally, GAO currently has ongoing work looking at which
nursing home characteristics, if any, affect the likelihood that a home
experienced a COVID-19 outbreak. If you would like, we would be happy
to follow up with your staff to further discuss this issue. We are also
aware of ongoing work from HHS OIG that will describe the
characteristics of the nursing homes that were hardest hit by the
pandemic (OEI-02-20-00490). This work should help provide clarity
regarding factors associated with nursing home COVID-19 outbreaks, as
studies published to date have had mixed results.
______
Questions Submitted by Hon. Robert P. Casey, Jr.
Question. To receive Medicare and Medicaid funding, nursing homes
must meet minimum Federal quality and safety standards and must also
submit annual cost reports. According to the Government Accountability
Office (GAO), these ``cost reports are the only publicly available
source of financial data for many [nursing facilities].'' In 2016, GAO
found that while the Centers for Medicare and Medicaid Services
collects information on nursing home revenue, it is not doing enough to
ensure that the information is both accurate and accessible to the
public.
In light of the pandemic, and the importance of ensuring that
Federal dollars are spent on things like resident care, infection
control, and ensuring an adequate workforce, how important is this cost
information and what can we do to ensure that it is accurately and
adequately reported?
Answer. As the question notes, GAO's 2016 report (GAO-16-700) made
two recommendations related to the issue of Skilled Nursing Facility
(SNF) expenditure data. Both of these recommendations remain open and
have not been implemented by CMS (see below). GAO maintains the
importance of making these data more accurate and accessible to the
public. While we have not specifically reviewed these issues in the
context of the COVID-19 pandemic, in our COVID-19 work we have made
similar recommendations that, if implemented, would improve the
transparency of nursing home information to the public, including
nursing home data on COVID-19 vaccinations of residents and staff.
Recommendation 1: To improve the accessibility and reliability
of SNF expenditure data, the Acting Administrator of CMS should
take steps to improve the accessibility of SNF expenditure
data, making it easier for public stakeholders to locate and
use the data.
Status: The agency concurred with this recommendation in 2016
and Stated that it would review the feasibility of increasing
the accessibility of this data. However, in August 2017, HHS
told GAO that it now believes that the cost of implementing
this recommendation would outweigh its benefits. HHS confirmed
in July 2019 that its position on this recommendation has not
changed. GAO continues to maintain that data on SNFs' relative
expenditures should be readily accessible to the public to
ensure transparency in SNF expenditures. As of November 2020,
HHS officials have not informed us of any actions taken to
implement this recommendation.
Recommendation 2: To improve the accessibility and reliability
of SNF expenditure data, the Acting Administrator of CMS should
take steps to ensure the accuracy and completeness of SNF
expenditure data.
Status: CMS did not concur with this recommendation. HHS
reported in 2016 that the amount of time and resources to
verify the accuracy and completeness of SNF expenditure data
could be substantial, without assurance of benefit to the
agency and the public. However, during the course of our work,
GAO found that CMS uses this expenditure data to update overall
SNF payment rates, in addition to using it for more general
purposes. Without taking steps to ensure the accuracy and
completeness of expenditure data, CMS risks developing SNF
payments rates that are based on unreliable data. As of
November 2020, HHS officials have not informed us of any
actions taken to implement this recommendation.
______
Prepared Statement of David Gifford, M.D., MPH, Chief Medical Officer,
American Health Care Association/National Center for Assisted Living
Chairman Wyden, Ranking Member Crapo, and distinguished members of
the Senate Finance Committee, thank you for making nursing homes and
long-term care (LTC) providers a priority as you examine how COVID-19
has impacted the Nation. The American Health Care Association and the
National Center for Assisted Living (AHCA/NCAL) appreciates the
opportunity to share our perspective regarding caring for seniors in
nursing homes amid the current COVID-19 crisis.
AHCA/NCAL represents more than 14,000 non-profit and proprietary
nursing homes, assisted living communities, and homes for individuals
with intellectual and developmental disabilities. The 2.5 million
Americans served in LTC facilities every day are some of the most
threatened by the SARS-coV-2 coronavirus (COVID-19).
LTC facilities (including nursing homes and other congregate
facilities for older adults) have been considered the epicenter of the
pandemic. As a geriatrician and the chief medical officer for AHCA/
NCAL, I can attest that COVID-19 is the greatest tragedy to impact our
residents and their families. Over 635,000 nursing home residents have
been infected and more than 130,000 have died.\1\ This virus has also
affected health care workers, with over half-a-million nursing home
staff becoming infected and over 1,600 having succumbed to the virus
to-date.\2\
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\1\ CDC Nursing Home COVID-19 Data Dashboard. Accessed on March 13,
2021 at https://www.cdc.gov/nhsn/covid19/ltc-report-overview.html.
\2\ CDC Nursing Home COVID-19 Data Dashboard. Accessible at https:/
/www.cdc.gov/nhsn/covid19/ltc-report-overview.html.
In addition, the pandemic has taken an emotional and physical toll
on residents, patients and staff. For nearly a year, family members
were unable to visit. Residents could not leave their rooms. They could
not see the smiles of the nurses and aides caring for them, hidden
behind masks. Our dedicated staff members did everything they could to
keep residents safe, engaged, and happy. But at the same time, they
constantly worried about becoming ill and/or infectingtheir loved ones
at home or their residents. Undoubtedly, this virus will leave
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psychological scars for many that will last a lifetime.
It is critical that we figure out what happened, why it happened,
and what we can do to keep it from ever happening again.
the nature of the virus
Nursing home residents are at the highest risk for complications
due to COVID-19. More than half are over the age 85 and suffer from
multiple chronic diseases, including dementia. According to the Centers
for Disease Control and Prevention (CDC), compared to younger
individuals, the risk of COVID-19 infections among the age group of our
residents is two times higher, but the risk of hospitalization is 80
times higher, and the risk of death is 7,900 times higher.\3\
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\3\ CDC Risk for COVID-19 Infection, Hospitalization, and Death By
Age Group. Updated February 18, 2021. Accessed on March 13, 2021 at
https://www.cdc.gov/coronavirus/2019-ncov/covid-data/investigations-
discovery/hospitalization-death-by-age.html.
Nursing home residents experienced a 20-percent mortality rate with
COVID-19--the highest of any other infection or disease we have ever
faced. A similarly high rate of infection and death was seen around the
world among older adults living in LTC facilities. Researchers tracking
COVID-19 data in the United States \4\ and world-wide \5\ consistently
found that LTC residents made up a small percentage of total cases yet
were a disproportionate share of each country's deaths in 2020.
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\4\ Kaiser Family Foundation. COVID-19: Long-term Care Facilities.
Accessed on March 13, 2021 at CDC, Risk for COVID-19 Infection,
Hospitalization, and Death By Age Group. Updated February 18, 2021.
Accessible at https://www.cdc.gov/coronavirus/2019-ncov/covid-data/
investigations-discovery/hospitalization-death-by-age.html.
\5\ Mathews A.W., Douglas J., Kamp J., and Yoon D. COVID-19 Stalked
Nursing Homes Around the World. Wall Street Journal. Published on line
on December 31, 2020. Accessed at https://www.wsj.com/articles/covid-
19-stalked-nursing-homes-around-the-world-11609436215.
It is important to understand the nursing home setting. Residents
depend on our nurses, aides, housekeepers, dietary staff and therapists
to help them with daily activities like eating, getting dressed and
bathing, and this care assistance often requires very close contact for
prolonged periods. Social distancing was not an option in long-term
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care.
As we now know, COVID-19 does not act like most respiratory
viruses. It commonly spreads through asymptomatic and pre-symptomatic
carriers,\6\ making it extremely difficult for providers to prevent its
entry and spread in LTC facilities. The incubation period for the virus
is longer than most viruses (up to 14 days). The length of a person's
infectious period (i.e., the ability to spread to others) is also
longer than typical respiratory viruses (up to 10 days). Worst of all,
it was found to have an airborne component of spread.\7\ All these
characteristics were not known early on during the pandemic. As a
result, many early recommendations from public health officials were
incorrect and therefore, ineffective at preventing spread.
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\6\ Johansson M.A., Quandelacy T.M., Kada S., et al. SARS-CoV-2
Transmission From People Without COVID-19 Symptoms. JAMA Network Open.
2021;4(1):e2035057; doi:10.1001/jamanetworkopen.2020.35057.
\7\ CDC Science Brief: SARS-CoV-2 and Potential Airborne
Transmission, updated Oct. 5, 2020, accessible at https://www.cdc.gov/
coronavirus/2019-ncov/more/scientific-brief-sars-cov-2.html.
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changing and conflicting government guidance
The Centers for Medicare and Medicaid Services (CMS) and the CDC
tried to keep pace with the evolving information about COVID-19,
issuing numerous requirements and guidance to nursing homes at an
unprecedented speed. Since the implementation of the public health
emergency,
CMS and CDC combined have released 55 major new requirements or
guidance to nursing homes in the areas of infection control, testing
and the use of personal protective equipment (PPE), or on average, at
least one per week. (This does not count the frequent minor updates or
modifications to guidance, nor all the Medicare and Medicaid payment
changes. Additionally, it does not include all the CMS guidance related
to 1135 waivers, the Five-Star rating system, and survey frequency.
There was also myriad guidance from other agencies, such as the
Department of Labor and the Occupational Health and Safety
Administration.)
In addition, many States issued orders and recommendations, which
often conflicted with other States or Federal guidance. This ever
evolving and conflicting guidance, scattered across multiple websites
and hundreds of pages, made it nearly impossible for providers to
follow consistent best practices to mitigate the spread of the virus.
Even though public health officials constantly churned out new
guidance, it was often too late and outdated by the time it was issued.
The timing of some of the major recommendations made by CMS and CDC are
depicted in the attached timeline (see last page) relative to the
number of cases and deaths in nursing homes. Early on, the public
health recommendations focused on a symptoms-based approach. CMS
required that staff be screened for symptoms and asked staff to stay
home if they had any one symptom suggestive of COVID-19. However,
screening only for symptoms meant missing asymptomatic staff who could
unwittingly spread the virus in the facility. Masks were not
recommended for use by all staff throughout the facility until almost 4
months into the pandemic in late June. This allowed the virus to spread
amongst staff members outside of designated COVID patient care areas.
Early on and without adequate testing available, residents were
cohorted based on symptoms, which sometimes resulted in asymptomatic or
pre-symptomatic residents spreading the virus in what were believed to
be COVID-free units or rooms.
lack of testing
Nursing home providers found it challenging to access affordable,
reliable, and timely tests until many months into the pandemic. Due to
the country's limited testing capabilities in beginning, LTC residents
were not made a priority for testing. Even when they were made a
priority by the CDC at the end of April, it was only for residents and
staff with symptoms, and tests were rarely available. When they were
available, it often took 5 days or more to receive the results. Testing
kits and supplies were not sent to nursing homes until August. Routine
surveillance testing was not required until September, six months after
the start of the pandemic.
The lack of adequate and timely testing impaired the ability of
providers to keep the virus at bay, as asymptomatic and pre-symptomatic
spread could continue undetected. Even when testing kits became
available in the fall of 2020, the initial lack of guidance and then
changing guidance on how to interpret test results between the
polymerase chain reaction (PCR) and antigen tests further compounded
the effectiveness of testing to prevent spread.
personal protective equipment shortages
Despite caring for the most vulnerable population when it comes to
COVID-19, LTC facilities were not made a priority for necessary
equipment. Even after numerous calls for help,\8\ it took months for
LTC residents and staff to be made the highest priority for PPE.
Worldwide supply chain issues left providers scrambling to find and
purchase quality PPE, such as N95 masks, gowns, and gloves. Many
suppliers delayed or limited the size of providers' orders, and many
providers got taken by scammers pretending to have legitimate PPE. In
addition, prices soared.
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\8\ COVID-19 Timeline, accessible at https://saveourseniors.org/
timeline/; accessed on March 13, 2021.
In many circumstances, staff had to use their ingenuity to make
their own masks, gowns and face shields. I recall getting calls one
night asking which type of material would be best for masks, and on a
weekend asking if rain ponchos work better as gowns than trash bags.
Academic research found that this lack of PPE was correlated with more
cases and deaths in nursing homes reporting PPE shortages.\9\
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\9\ McGarry B.E., Grabowski D.C., Barnett M.L. Severe Staffing and
Personal Protective Equipment Shortages Faced By Nursing Homes During
the COVID-19 Pandemic. Health Affairs (Millwood). 2020 Oct;39(10):1812-
1821; doi: 10.1377/hlthaff.2020.01269. Epub 2020 Aug 20. PMID:
32816600.
In May, the Federal Emergency Management Agency (FEMA) organized
two shipments of PPE supplies that would each cover the needs of a
nursing home for one week.\10\ The first shipment arrived in mid-May to
early June, and the second shipment in July. These two shipments were
an amazing logistical feat but did not start until 10-12 weeks into the
pandemic. Also, they did not contain any N95 masks given the continued
worldwide shortages. For many, the PPE waswelcomed and lifesaving, but
there were several shipments that included PPE that either could not be
used,\11\, \12\ was past its expiration date, or did not
meet CDC or CMS standards.\13\ In one case a provider relayed to me,
CMS inspectors would not use the PPE when offered to them during their
on-site infection control inspection.
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\10\ FEMA press release. ``Coronavirus pandemic response: PPE
packages for Nursing Homes,'' released May 2, 2020. Accessed on March
14, 2021 at https://www.fema.gov/fact-sheet/coronavirus-pandemic-
response-ppe-packages-nursing-homes.
\11\ Joran Rau. ``Federal Help Falters as Nursing Homes Run Short
of Protective Equipment.'' Kaiser Health News, posted June 11, 2020;
accessible at https://khn.org/news/federal-help-falters-as-nursing-
homes-run-short-of-protective-equipment/.
\12\ Priscilla Alvarez and Daniella Diaz. ``Nursing homes receive
defective equipment as part of Trump administration supply
initiative.'' CNN Politics, updated Thursday June 11, 2020; accessible
at https://www.cnn.com/2020/06/10/politics/nursing-homes-ppe-defective-
equipment-fema/index.html.
\13\ Katie Smith Sloan, CEO of LeadingAge, Letter to Vice President
on June 11, 2020; accessible at https://www.leadingage.org/sites/
default/files/LeadingAge%20Pence%20Letter%20611
20_final.pdf.
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the impact of community spread
Due to the nature of how COVID-19 spreads, the lack of PPE and
testing, and ever shifting guidance, it is not surprising that the
principal factor leading to COVID-19 outbreaks in nursing homes has
been repeatedly shown to be related to the amount of spread in the
surrounding community. Even the best nursing homes with the most
rigorous infection control practices could not stop this highly
contagious, invisible enemy.\14\ Academic experts at Harvard
University,\15\ Brown University \16\ and the University of Chicago
\17\,\18\ all found that the primary predictor of a nursing
home experiencing an outbreak is the prevalence of COVID-19 in the
surrounding community. Other factors that predicted outbreaks related
to increased human-to-human interaction, which clearly increases the
chance the virus can spread. These factors meant larger facilities,
especially those in urban areas where there is higher proportion of
minority residents, were more likely to experience outbreaks.
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\14\ Opinion by David C. Grabowski, R. Tamara Konetzka, and Vincent
Mor. Opinion: We can't protect nursing homes from COVID-19 without
protecting everyone. Washington Post. Published June 25, 2020;
available at https://www.washingtonpost.com/opinions/2020/06/25/we-
cant-protect-nursing-homes-covid-19-without-protecting-everyone/.
\15\ Abrams H.R., Loomer L., Gandhi A., Grabowski D.C.
Characteristics of U.S. Nursing Homes With COVID-19 Cases. J Am Geriatr
Soc. 2020 Aug;68(8):1653-1656; doi: 10.1111/jgs.16661. Epub 2020 Jul 7.
\16\ White E.M., Kosar C.M., Feifer R.A., Blackman C., et al.
Variation in SARS-CoV-2 Prevalence in U.S. Skilled Nursing Facilities.
J Am Geriatr Soc. 2020 Oct;68(10):2167-2173; doi: 10.1111/jgs.16752.
Epub 2020 Aug 21. PMID: 32674223 PMCID: PMC7404330 DOI: 10.1111/
jgs.16752.
\17\ Konetzka R.T., Gorges R.J. Nothing Much Has Changed: COVID-19
Nursing Home Cases and Deaths Follow Fall Surges. J Am Geriatr Soc.
2021 Jan;69(1):46-47; doi: 10.1111/jgs.16951. Epub 2020 Nov 20.
\18\ Gorges R.J., Konetzka R.T. Factors Associated With Racial
Differences in Deaths Among Nursing Home Residents With COVID-19
Infection in the U.S. JAMA Network Open. 2021 Feb 1;4(2):e2037431; doi:
10.1001/jamanetworkopen.2020.37431. PMID: 33566110.
The same academic researchers could not find an association with
COVID-19 outbreaks and other characteristics, such as the facility's
Five-Star Rating on Nursing Home Compare; whether the facility had a
prior violation related to infection control; or whether it was for-
profit, part of a chain, or had a high Medicaid census. This
relationship of COVID-19 cases in nursing homes mirroring the
prevalence in the community continued through the fall based on
analyses by the Kaiser Family Foundation \19\ and CDC.\20\
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\19\ Priya Chidambaram and Rachel Garfield. Patterns in COVID-19
Cases and Deaths in Long-Term Care Facilities in 2020. Kaiser Family
Foundation. Coronavirus. Published: January 14, 2021; https://
www.kff.org/coronavirus-covid-19/issue-brief/patterns-in-covid-19-
cases-and-deaths-in-long-term-care-facilities-in-2020/.
\20\ Bagchi S., Mak J., Li Q., et al. Rates of COVID-19 Among
Residents and Staff Members in Nursing Homes--United States, May 25-
November 22, 2020. MMWR Morb Mortal Wkly Rep 2021;70:52-55; doi: http:/
/dx.doi.org/10.15585/mmwr.mm7002e2.
With hindsight it is easy to criticize public officials and health
care providers for failures during the pandemic. This is unfair, given
the lack of knowledge about this virus. However, what was evident was
that the LTC community was left behind, forgotten, or even blamed. This
further demoralized our health care heroes in LTC who were giving their
all and risking their lives as well as their family members' lives but
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received inadequate support.
It is critical that we figure out what we can do to prevent such
tragedy from ever happening again. But in order to move forward, we
must also reflect on the long-standing challenges within the LTC
profession that COVID-19 exposed and exacerbated. Providers acknowledge
that we can and need to do better to meet the needs of our Nation's
seniors--continuous quality improvement is part of who we are.
Let me take a moment to highlight several historical challenges
facing long term care that the pandemic further exposed. These include
staffing, health care disparities, infection control, and
reimbursement.
workforce crisis
Long-term care was already dealing with a workforce shortage prior
to COVID, and the pandemic has only magnified the crisis due to staff
members getting sick, having to isolate, or a lack of childcare
options. At the same time, the pandemic required numerous new tasks
(e.g., screening all personnel upon entry, reporting cases daily,
serving meals in rooms, donning PPE for every resident) and more one-
on-one care to help prevent spread, all requiring more staff. We
commonly heard the phrase ``all-hands-on deck'' to help meet the
residents' needs and new recommendations and guidance.
During the pandemic, AHCA/NCAL urged governors to help address the
workforce shortage by outlining strategies in a roadmap for States in
May 2020.\21\ We also developed free online courses to help train
temporary caregivers (nurse aides and feeding assistants) to help fill
the gap the pandemic created. Additionally, AHCA/NCAL urged Congress
and the administration to direct financial aid to long term care
facilities, so that providers could use those resources to respond to
the crisis, including by hiring more staff and offering hero pay. In a
survey of nursing home providers conducted in November 2020, 70 percent
of nursing homes had hired additional staff and nine out of 10 asked
staff to work overtime and provided hero pay.\22\
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\21\ AHCA/NCAL Long Term Care Workforce Roadmap for Governors and
States; https://www.ahcancal.org/Survey-Regulatory-Legal/Emergency-
Preparedness/Documents/COVID19/AHCANCAL-Workforce-Roadmap.pdf.
\22\ AHCA Survey State of the Nursing Home Industry; https://
www.ahcancal.org/News-and-Communications/Fact-Sheets/FactSheets/State-
of-Nursing-Home-Industry_Dec2020.pdf.
We need ongoing staff support as this pandemic continues, but we
also need a more long-term solution. AHCA/NCAL has been highlighting
this workforce crisis for years, including testifying to Congress twice
in 2019. It is time that we address this. We need a comprehensive
strategy to recruit more health care heroes to serve in long-term care.
infection control
As described earlier, prior infection citations have not been shown
to be associated with COVID-19 outbreaks or cases. However, nursing
homes have been cited for infection control practices historically.\23\
These trends led CMS to issue an extensive set of new regulations in
November 2016 phased in over 3 years, including the requirement for a
designated infection preventionist in every nursing home starting in
November 2019.\24\ These new requirements and regulations were just
taking effect when the pandemic hit.
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\23\ GAO. Infection Control Deficiencies Were Widespread and
Persistent in Nursing Homes Prior to COVID-19 Pandemic. GAO-20-576R.
Published: May 20, 2020. Publicly Released: May 20, 2020; https://
www.gao.gov/products/gao-20-576r.
\24\ Medicare and Medicaid Programs: Reform of Requirements for
Long-Term Care Facilities. A Rule by the Centers for Medicare and
Medicaid Services on 10/04/2016 published in Federal Register;
available at https://www.federalregister.gov/documents/2016/10/04/2016-
23503/medicare-and-medicaid-programs-reform-of-requirements-for-long-
term-care-facilities.
Unfortunately, many infection preventionists became ill or had to
isolate following exposure or presenting with symptoms. This
highlighted the importance of having the infection preventionist
position met not by a single person but adjusted based on the size and
needs of the facility. A large nursing home with 300 residents has
different infection control demands than a small, rural nursing home
with 20 residents. AHCA supported the infection preventionist
regulations anddeveloped a certification program to train over 3,000
infection preventionists before they went into effect. However, the
nursing shortage continues to make it challenging to identify infection
preventionists, as many are hired away by hospitals. To meet the need
for infectionpreventionists, we need help with recruiting and retaining
registered nurses (RNs) to serve in this role.
disparities in care
The pandemic has disproportionately impacted minority populations
more than others. This has been no different in nursing
homes.\25\, \26\ The disparities in care outcomes were known
prior to COVID.\27\ Academic experts who have analyzed the differences
in outcomes among African American and Latino residents in long-term
care find the disparities to be related to both the overall quality of
the facility and the Medicaid reimbursement challenges.\28\,
\29\ This has led several academic and policy experts to call for more
resources and changes to Medicaid to address these
disparities.\30\, \31\ As a country, we need to step up and
make sure that minority populations have equitable health-care coverage
and supports, including in long-term care. This in part, means properly
funding health-care programs like Medicaid, so that long-term care
providers who care for people of color have the staffing and other
resources needed to meet their residents' needs.
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\25\ Gorges R.J., Konetzka R.T. Factors Associated With Racial
Differences in Deaths Among Nursing Home Residents With COVID-19
Infection in the U.S. JAMA Network Open. 2021 Feb 1;4(2):e2037431; doi:
10.1001/jamanetworkopen.2020.37431. PMID: 33566110.
\26\ Li Y., Cen X., Cai X., Temkin-Greener H. Racial and Ethnic
Disparities in COVID-19 Infections and Deaths Across U.S. Nursing
Homes. J Am Geriatr Soc. 2020 Nov;68(11):2454-2461; doi: 10.1111/
jgs.16847. Epub 2020 Sep 28.
\27\ Mack D.S., Jesdale B.M., Ulbricht C.M., Forrester S.N.,
Michener P.S., Lapane K.L. Racial Segregation Across U.S. Nursing
Homes: A Systematic Review of Measurement and Outcomes. Gerontologist.
2020 Apr 2;60(3):e218-e231; doi: 10.1093/geront/gnz056. PMID: 31141135.
\28\ Campbell L.J., Cai X., Gao S., Li Y. Racial/Ethnic Disparities
in Nursing Home Quality of Life Deficiencies, 2001 to 2011. Gerontol
Geriatr Med. 2016 Jun 6;2:2333721416653561; doi: 10.1177/
2333721416653561. eCollection 2016 Jan-Dec. PMID: 27819015.
\29\ Barton Smith D., Feng Z., Fennell M.L., et al. Separate and
unequal: Racial segregation and disparities in quality across U.S.
nursing homes. Health Aff (Millwood). Sep-Oct 2007;26(5):1448-58; doi:
10.1377/hlthaff.26.5.1448. PMID: 17848457 DOI: 10.1377/
hlthaff.26.5.1448.
\30\ Ibid #27.
\31\ Grabowski D.C. Strengthening Nursing Home Policy for the
Postpandemic World: How Can We Improve Residents' Health Outcomes and
Experiences? Commonwealth Fund; issue briefs August 20, 2020; https://
www.commonwealthfund.org/publications/issue-briefs/2020/aug/
strengthening-nursing-home-policy-postpandemic-world.
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financial crisis
Prior to the COVID-19 pandemic, Medicaid underfunding plagued
nursing homes for years. More than 60 percent of all nursing home
residents rely on Medicaid to cover their daily care. However, Medicaid
reimbursements only cover 70 to 80 percent of the actual cost of care
in a nursing home. The intense needs of our residents require dedicated
staff to provide hands-on care and consequently, labor makes up an
enormous proportion of everyday expenses (roughly 70 percent). The
chronic Medicaid underfunding makes it challenging for providers to
offer competitive wages and benefits and make other investments in
their workforce.
Over the last year, long-term care facilities have faced
skyrocketing costs. Providers have dedicated extensive resources to
fighting COVID-19. The costs associated with routine testing, PPE, and
staffing have pushed many facilities to the brink. The Provider Relief
Fund created by Congress has been a lifeline, allowing nursing homes to
stay open and providers to purchase resources to protect their
residents and staff. However, nursing homes only received approximately
$13 billion from the Provider Relief Fund, or roughly 7 percent of the
fund's total. This is less than half of what nursing homes spent on PPE
and additional staffing alone in 2020 ($30 billion), and these
additional costs are expected to continue in 2021 as the pandemic
lingers.
In addition, revenue has significantly declined due to fewer
patients coming from the hospital as well as fewer potential residents
seeking long term care. Nationally, nursing home occupancy
significantly dropped from 80.2 percent in January 2020 to 68.2 percent
in March 2021.\32\ This has resulted in $11.3 billion in losses to
nursing homes in 2020 and is projected to increase in 2021 to $22.6
billion. AHCA/NCAL did an extensive analysis estimating nursing
homefinancials and found that in combining anticipated COVID costs and
projected losses, the industry expects to lose $94 billion over a 2-
year period (2020-2021).\33\
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\32\ AHCA analysis of CDC NHSN data; accessible at https://
www.ahcancal.org/Data-and-Research/Pages/default.aspx; downloaded on
March 14, 2021.
\33\ AHCA Issue Brief: Protect Access to Long Term Care for
Vulnerable Residents; https://d3dkdvqff0zqx.cloudfront.net/groups/ahca/
attachments/protect%20access%20to%20long%20
term%20care_ib.pdf.
Today, thousands of LTC facilities are on the verge of collapse,
with more 1,600 nursing homes in danger of closing their doors this
year. This has real consequences for residents and their families.
Again, most residents are older adults living with multiple underlying
health conditions, and they require a high-level of specialized care.
Closures leave residents displaced from their long-standing communities
and loved ones. Closures also reduce options for quality care,
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especially in rural areas.
In order to protect access to long-term care for vulnerable seniors
and improve staffing issues, Medicaid reimbursement needs to be
reformed as numerous academic experts have advised.\34\,
\35\, \36\ Medicaid reimbursement rates must catch up with
the cost of care. Nursing homes need adequate funding and resources in
order to provide quality care. We urge policy-makers and stakeholders
to work toward long-term solutions that tackle this systemic issue.
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\34\ Grabowski D.C., Mor V. Nursing Home Care in Crisis in the Wake
of COVID-19. JAMA. 2020 Jul 7;324(1):23-24; doi: 10.1001/
jama.2020.8524. PMID: 32442303 DOI: 10.1001/jama.2020.8524.
\35\ Grabowski D.C. Strengthening Nursing Home Policy for the
Postpandemic World: How Can We Improve Residents' Health Outcomes and
Experiences? Commonwealth Fund; issue briefs August 20, 2020; https://
www.commonwealthfund.org/publications/issue-briefs/2020/aug/
strengthening-nursing-home-policy-postpandemic-world.
\36\ R. Tamara Konetzka, Caring for Seniors Amid the COVID-19
Crisis. Testimony Before the United States Senate Special Committee on
Aging. May 21, 2020; accessible at https://www.aging.senate.gov/imo/
media/doc/SCA_Konetzka_05_21_20.pdf.
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how we move forward: the care for our seniors act
The pandemic has led the nursing home sector to reflect what can be
done to prevent such tragedy from ever happening again and how to
address longstanding challenges COVID-19 exposed. After reviewing the
evidence, expert recommendations, and the Commission for Safety and
Quality in Nursing Homes report,\37\ AHCA and LeadingAge announced the
Care for Our Seniors Act.\38\ This is a comprehensive plan aimed at
offering solutions that will improve the quality of care in our
Nation's nursing homes as we begin to look towards a post COVID-19
environment. This plan recommends policies and steps to improve
clinical care, strengthen and support our workforce, improve oversight,
and modernize our physical structures. Specifically, we are supporting:
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\37\ Independent Nursing Home COVID-19 Commission Findings Validate
Unprecedented Federal Response. Issued on September 16, 2020; available
at https://www.cms.gov/newsroom/press-releases/independent-nursing-
home-covid-19-commission-findings-validate-unprecedented-federal-
response.
\38\ AHCA and LeadingAge's Care For Our Seniors Act; available at
www.ahcancal.org/solutions.
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Clinical--Enhance Quality Care:
24-hour R.N.: We support a new Federal requirement that each
nursing home have an R.N. on staff 24 hours a day and provide
recommendations on how to effectively implement this requirement.
Enhanced infection preventionist: We will help establish an
updated guideline for staffing infection preventionists in each nursing
home based on proven, successful strategies. This includes proper
funding and workforce availability to effectively implement meaningful,
sustained changes.
Minimum 30-day supply of PPE: We support efforts to require a
minimum supply of PPE in nursing homes, which will be supported by
ongoing Federal/State stockpiles with PPE that is acceptable for
health-care use.
Workforce--Strengthen and Support Front-line Caregivers:
Recruit and retain more long-term care workers: We support
implementing a multi-phase tiered approach leveraging Federal, State,
and academic entities. This includes loan forgiveness for new graduates
who work in LTC, tax credits for licensed LTC professionals, programs
for affordable housing and childcare assistance, and increased
subsidies to professionals' schools whose graduates work in nursing
homes for at least 5 years.
Oversight--Improve Systems to Be More Resident-Driven
Survey improvements for better resident care: We support
development of an effective oversight system and processes that promote
improved care and protect residents, consistent with CMS standards.
Chronic poor-performing nursing facilities: The survey system
needs a process to help turn chronic poor-performing facilities around
or close the facility. We are proposing a five-step process to address
such facilities.
Publicly report customer satisfaction: Nursing homes are the
only health-care setting in which CMS collects and publicly reports
quality data that does not include customer satisfaction. We recommend
adding this measure to the government's Five-Star rating system to help
monitor the quality of a nursing home for family members and guide
consumer choice.
Structural--Modernize for Resident Dignity and Safety
Shift to private rooms: The average nursing home is around 40 to
50 years old. The traditional care models are no longer considered
appropriate to provide
person-centered care. One central aspect of this shift is a greater
emphasis on autonomy, dignity and privacy. Private rooms also support
infection control best practices. We support the development of a
national study producing data on conversion costs and a recommended
approach to make this shift.
Long-lasting transformation that will protect our residents
requires a considerable investment in the LTC profession. As a health-
care provider that relies almost entirely on government reimbursement
(Medicare and Medicaid), nursing homes cannot make substantial reforms
on their own. They need the support of Federal and State policy-makers
and resources.
conclusion
Long-term care providers welcome a national discussion regarding
how we can improve in light of the COVID-19 pandemic. We urge the
Senators of this committee and the entire Congress to recognize the
nature of this virus and that we need a collaborative approach to
address longstanding challenges in our Nation's nursing homes.
Focusing solely on regulations fails to recognize the cause of this
crisis, nor does it help solve it. The reality is that many of these
outbreaks have occurred because nursing homes were located in
communities with high rates of spread and because long-term care
residents and staff were not prioritized by public health officials,
leaving providers scrambling for testing, PPE, and staffing resources.
Just like hospitals, we called for help from the very beginning. But
unlike hospitals, our calls often went unanswered or came too late. In
our case, it has been difficult to get anyone to listen. Prioritizing
long-term care facilities in emergency situations is key, as we have
seen in other emergencies, such as natural disasters.
Despite a year of tragedy, a virus that will linger well into the
future, and historic challenges within long-term care, I remain
optimistic. We have three remarkably safe and effective vaccines.
Nursing home residents and staff were made a priority to receive the
vaccine by the CDC and the vast majority of Governors. As a result,
nursing home cases and deaths have declined dramatically since mid-
December and faster than the general population. This has allowed CDC
and CMS to update guidance to allow more in-person visitations. We are
elated to see families and residents reunited. Making our nursing homes
a top priority for the vaccine demonstrates the power of putting long-
term care and our Nation's seniors first.
I want to end by saying that our hearts go out to the residents and
their family members who have suffered through the past year, separated
from each other--in some cases forever. Our thoughts also go to the
long-term caregivers who have given their all this past year, often
without the recognition they deserve.
I have spoken with providers, families and other stakeholders who
all agree that the health-care system needs to be better aligned to
achieve the outcomes we all want. If any good can come out of the
pandemic, we are hopeful that it can serve as the catalyst needed to
institute meaningful change.
On behalf of the residents, their families and the staff in nursing
homes across the country, thank you for your dedication and leadership
to tackle the long-term care needs of our seniors and individuals with
disabilities. Your ongoing help and support mean more now than ever
before. Ensuring that essential and necessary resources are provided to
long-term care providers is critical to protecting our Nation's most
vulnerable. We look forward to having constructive discussions on
solutions with you to combat COVID-19 and usher in a stronger long-term
care system.
TIMELINE:
COVID-19 AND NURSING HOMES
Despite repeated calls for help, nursing homes did not receive
resources or priority for months. Even then, the high amount of spread
in surrounding communities made it impossible for nursing homes to
prevent the virus from entering their facilities. This timeline
identities major regulatory, policy and resource supports skilled
nursing facilities (SNFs) received during the pandemic, as compared to
the timing of cases and deaths.
[GRAPHIC] [TIFF OMITTED] T1721.026
.epsThe Federal Government began collecting and reporting nursing home
cases and deaths in May 2020. Since the implementation of the public
health emergency, CMS and CDC combined have released 55 (or on average
at least one per week) major new requirements or guidance in areas of
infection control, testing and PPE use. This does not count minor
guidance updates or modifications nor payment changes.
______
Questions Submitted for the Record to David Gifford, M.D., MPH
Questions Submitted by Hon. Ron Wyden
Question. The Centers for Medicare and Medicaid Services (CMS)
issued an interim final rule last year that required nursing homes to
report COVID-19 data to the Centers for Disease Control and Prevention
on a weekly basis beginning May 17, 2020. These data included COVID-19
infections, COVID-19 deaths, and the availability of key equipment and
workers at individual nursing homes. The data have proved to be helpful
for the public, policy-makers, and industry stakeholders to track the
pandemic, and related issues, in these care settings. However, to date,
CMS has not required nursing homes to provide such data prior to May 8,
2020, despite calls from Senate Democrats to do so. In September 2020,
the Government Accountability Office (GAO) noted that ``by not
requiring nursing homes to submit data from the first 4 months of 2020,
HHS is limiting the usefulness of the data in helping to understand the
effects of COVID-19 in nursing homes.'' GAO went on to recommend that
``HHS, in consultation with CMS and CDC, develop a strategy to capture
more complete data on COVID-19 cases and deaths in nursing homes
retroactively back to January 1, 2020.''
Do you support GAO's recommendation? Why or why not? Please briefly
explain.
Answer. COVID-19 cases among resident and staff were reported by
nursing homes to State or local public health agencies since the
beginning of the pandemic. As pointed out by the GAO, these data
systems did not readily communicate with CDC or integrate to create a
national database. As a result, CMS issued an interim final rule
mandating all Medicare or Medicaid certified nursing homes to submit
case counts on a weekly basis to the CDC's National Healthcare Safety
Network (NHSN) system starting in May 2020. This resulted in duplicate
reporting requirements for nursing homes all because State and Federal
systems could not communicate effectively.
We support States making the data they have on COVID-19 case counts
prior to May 2020 available to the CDC or other Federal agencies for
research purposes to learn about the pandemic and how to better combat
the spread of COVID-19. We are not supportive of asking providers to go
back through their medical records to identify cases and provide data
they have already provided solely because State and Federal systems are
not integrated. This would take an extensive amount of time and
resources away from resident care, shifting the burden of data
collection onto providers at a time staff are already stretched thin
due ongoing workforce challenges and the pressures of the pandemic.
A lesson that should be addressed from this pandemic has been that
State and Federal public health data systems are underfunded,
underdeveloped and under-maintained. The public health infrastructure
needs more Federal funding to modernize their data systems and make
sure they are integrated. We are currently experiencing the same
problem with State immunization registries. They do not integrate with
Federal data systems and long-term care (LTC) pharmacies and providers
are having to enter duplicate immunization data in State immunization
registries and CDC Federal registries. This is not a good use of
health-care staff's time. They should be devoted to making sure
residents and staff receive the vaccine and monitoring their reaction,
not entering the same data into multiple systems because the States and
Federal Governments are not collaborating cohesively.
Question. A recent paper published by the National Bureau of
Economic Research noted that people who receive treatment in nursing
homes owned by private equity firms have worse health outcomes than
those living in facilities under other ownership structures.\1\ This
paper adds evidence to reports of worse outcomes associated with
private equity's investment in the nursing home industry. Nursing homes
have also become popular investments for real estate investment trusts
(REITs), which often lease back properties to private equity firms or
other related parties. The involvement of private equity in the nursing
home industry has been of interest to the Finance Committee for more
than a decade, and the role of private equity and for-profit ownership
in the nursing home industry was raised in testimony and questions at
the hearing. Several reports from Federal agencies have suggested the
need for more thorough information on facility
ownership.\2\, \3\
---------------------------------------------------------------------------
\1\ https://www.nber.org/papers/w28474.
\2\ https://oig.hhs.gov/oei/reports/oei-04-11-00591.pdf.
\3\ https://www.gao.gov/assets/gao-10-710.pdf.
Please provide a list of all private equity firms and real estate
investment trusts (REIT) that are currently members of AHCA, or have
been within the last 5 years. In your response, please include
instances in which a subsidiary (or an otherwise related party) of a
private equity firm or REIT--e.g., a nursing home chain owned by a
private equity company, or that leases a large portion of its
facilities from a REIT--is an AHCA member, noting the parent company,
---------------------------------------------------------------------------
controlling entity, or related party.
Answer. AHCA does not collect information from our members nor have
access to CMS's Medicare Provider Enrollment, Chain, and Ownership
System (PECOS) data on private equity, REIT or controlling party
involvement with nursing homes or ``chain-owned'' nursing homes.
Question. Section 6101 of the Affordable Care Act (ACA) sought to
increase ownership transparency within the industry, but to date, the
provision has not been fully implemented or enforced by the Centers for
Medicare and Medicaid Services. Does AHCA support the full
implementation of section 6101?
Answer. AHCA's background and position on section 6101 of the ACA
is outlined in our policy memo available at https://www.ohca.org/
uploads/old/ppac_disclosure_of_ownership.pdf. However, clarity on
definitions and using existing reporting requirements need to be taken
into consideration so that duplicative reporting is not required. CMS
did implement transparency reporting requirements in 2011, which
nursing homes comply with (see: https://www.cms.gov/Medicare-Medicaid-
Coordination/Fraud-Prevention/Medicaid-Integrity-Education/Downloads/
ebulletins-providerenrollment-disclosureownership.pdf). We are
supportive of making this information more easily accessible than CMS
and many States currently offer.
Question. Beyond the provisions of section 6101, does AHCA support
additional transparency into nursing home ownership, financial
arrangements, use of government funds, and worker pay?
Answer. AHCA is supportive of transparency on ownership. We believe
much of the transparency data that many members of the public, policy-
makers and the media are asking for are currently collected. We should
use the existing data before mandating additional and potentially
unnecessary data collection efforts.
Also, we believe the most important issue for residents and their
families is transparency on the quality of the care being provided,
regardless of ownership. Proper resources should be devoted to assuring
that nursing home residents' care is met, which should be reflected in
transparency of quality outcomes. Creating additional reporting and
bureaucracy that diverts resources away from resident care is not
helpful.
Question. COVID-19's toll on nursing homes has not been limited to
viral infections. Residents have suffered mentally and physically, and
had less access to family members and patient advocates. On March 10,
2021, the Centers for Medicare and Medicaid Services issued new
guidance that allows for residents to more easily receive visitors. On
the same day, the Centers for Disease Control and Prevention issued
Updated Healthcare Infection Prevention and Control Recommendations in
Response to COVID-19, which stated ``quarantine is no longer
recommended for residents who are being admitted to a post-acute care
facility if they are fully vaccinated and have not had prolonged close
contact with someone with SARS-coV-2 infection in the prior 14 days.''
The committee has received written testimony for this hearing from
medical experts raising concerns that the new guidance may be overly
permissive, and could put nursing home residents in danger,
particularly if COVID-19 variants breakthrough vaccine protections. On
the other hand, some advocates have called for more permissive
visitation guidelines.
As a trained physician, do you have any concerns about the guidance
that was issued?
Answer. As with all medical care decisions, there are risks and
benefits to each decision, medication, test or procedure ordered for a
patient. One needs to balance the risks and benefits, which may not be
interpreted the same between two different individuals with the same
situation. In the case of allowing or not allowing visitations, we have
faced this same dilemma. Allowing visitors could increase the chances
of viral spread, but not allowing visitors increases the risk of
isolation and decline in residents. The new guidance we believe takes
the risks and benefits into consideration. As with each new guidance,
there remains unanswered questions about how to apply the guidance to
specific situations. Nursing homes have demonstrated good faith efforts
to implement each new guidance but will need clarity from time to time
from CDC. Getting that clarity or not taking into consideration good
faith efforts to adoption new guidance has been a frustration we have
heard over and over again from providers.
Question. Do nursing homes and long-term care facilities need
additional guidance to properly dial visitation?
Answer. As we learn more about how the virus spreads, how effective
preventive measures are as well as the effectiveness of being
vaccinated, we need CMS and CDC to update their guidance about how
residents can participate in communal dinning, activities, travel
outside the facility as well as family visitation. In addition,
screening and testing procedures currently in place are predicated on
what we knew last summer and fall prior to vaccination and variants.
We need CMS and CDC to update guidance on a regular basis but also
to provide enough lead time for providers to change their practices.
For example, the reopening guidance went into effect immediately. As a
result, we had family members showing up at the facility that same day
demanding entry when the facility perhaps did not have personal
protective equipment (PPE) for visitors or procedures in place to allow
safe visitation described in the CMS guidance document.
Question. Preliminary research conducted by Columbia University
researchers suggests that the Pfizer and Moderna vaccines were up to 12
times less effective at neutralizing the B.1.351 COVID-19 variant
(``South African variant'') than earlier strains of the coronavirus.\4\
The researchers also found that convalescent plasma was 9 times less
effective against the South African variants, leading them to write
``[t]aken together, the overall findings are worrisome, particularly in
light of recent reports that both Novavax and Johnson & Johnson
vaccines showed a substantial drop in efficacy in South Africa.''\5\
The researchers went on to write, ``mutationally, this virus is
traveling in a direction that could ultimately lead to escape from our
current therapeutic and prophylactic interventions directed to the
viral spike. If the rampant spread of the virus continues and more
critical mutations accumulate, then we may be condemned to chasing
after the evolving SARS-CoV-2 continually, as we have long done for
influenza virus.''\6\ The Centers for Disease Control and Prevention
(CDC) has previously found suspected cases of reinfection among nursing
home residents who previously tested positive for COVID-19.\7\
Similarly, a paper published earlier this year in The Lancet suggested
that a resurgence in COVID-19 cases in the Brazilian city of Manaus may
have been due to a new variant (known as P1 or ``Brazilian variant'')
that ``may evade immunity generated in response to previous
infections.''\8\
---------------------------------------------------------------------------
\4\ https://www.nature.com/articles/s41586-021-03398-
2_reference.pdf?utm_medium=affiliate&
utm_source=commission_junction&utm_campaign=3_nsn6445_deeplink_PID100024
933&utm_
content=deeplink.
\5\ https://www.nature.com/articles/s41586-021-03398-
2_reference.pdf?utm_medium=affiliate&
utm_source=commission_junction&utm_campaign=3_nsn6445_deeplink_PID100024
933&utm_
content=deeplink.
\6\ https://www.nature.com/articles/s41586-021-03398-
2_reference.pdf?utm_medium=affiliate&
utm_source=commission_junction&utm_campaign=3_nsn6445_deeplink_PID100024
933&utm_
content=deeplink.
\7\ https://www.cdc.gov/mmwr/volumes/70/wr/mm7008a3.htm.
\8\ https://www.thelancet.com/article/S0140-6736(21)00183-5/
fulltext.
Question. The South African and Brazilian variants continue to
circulate in the United States.\9\ What is your level of concern about
the danger that these and other COVID-19 variants may pose to nursing
homes, particularly residents who have been most vulnerable to the
disease?
---------------------------------------------------------------------------
\9\ https://www.cdc.gov/coronavirus/2019-ncov/transmission/variant-
cases.html.
Answer. The variants pose a significant concern to both vaccine
effectiveness and the current infection control practices. The lack of
widespread genetic testing also makes understanding how these viruses
are spreading in long term care and if they are more virulent difficult
to determine. Funding to State public health laboratories is needed to
expand genetic testing and to also evaluate residents who test positive
after vaccination. Currently, our members routinely hear that the
vaccines are not 100-percent effective, so we expect to see some
residents who are fully vaccinated test positive. There is little
evaluation being conducted to determine if these post-vaccination
infections are the result of variants or not. Similarly, we do not know
if PPE recommendations and source control masks are as effective with
this new variant and if the airborne component of spread is more
prevalent. Funding to NIH and CDC to support more rapid research is
---------------------------------------------------------------------------
needed.
Question. Is additional surveillance necessary to detect the spread
of viral variants? What types of surveillance, if any, should be
implemented in regards to the nursing home industry specifically?
Answer. Yes, as mentioned above, more funding is needed to public
health and research institutions to expand genetic testing and contact
tracing of residents and staff who test positive, particularly those
who have been fully vaccinated. CDC and CMS also need to update their
testing surveillance guidance that takes into consideration vaccination
status but also persistent low levels of viral shedding at non-
infectious levels causing PCR positive tests. These ``false positive''
PCR tests trigger changes in visitation, testing and cohorting
procedures in nursing homes that may not be necessary. Understanding
persistent long-term viral particle shedding is needed to understand
how to use PCR and Antigen testing in LTC.
Question. What steps has the industry taken to prepare itself for
the possible need for rapidly distributing booster shots to protect
against variants? In your view, what would be the best model to
accomplish such a rollout, and what would be a reasonable amount of
time?
Answer. We are working with a coalition of LTC pharmacy providers,
LTC provider associations and national associations representing State
public health and immunization programs to develop a more efficient way
to enroll LTC pharmacies and LTC providers in State immunization
programs and registries. This would streamline the process for nursing
homes and other long-term care facilities to offer booster shots to
residents and staff on-site, which is a critical component of any
vaccination effort in long-term care. AHCA/NCAL also plans to build
upon its existing #GetVaccinated campaign (https://getvaccinated.us/)
to educate and encourage LTC staff to get a booster shot when made
available to them.
One challenge is the inability of State immunization registries to
interface effectively with CDC and other Federal databases. Funding is
desperately needed to improve the public health infrastructure at CDC
and State public health agencies with respect to immunization
registries and infection disease reporting. The inability of these
systems to share data coupled with its dated, inefficient
infrastructure does not allow easy modifications to facilitate tracking
during an epidemic or pandemic. This has been a significant hinderance
and source of frustration for many during the COVID-19 pandemic. This
can be explained by years of poor public health funding for adequate
infrastructure. Congressional support to modernize CDC's and State
public health databases would make a significant difference.
Additionally, funding to help CMS build data systems to track key
leadership positions in skilled nursing facilities (SNFs) is needed to
get information out quickly. CMS currently lacks a data system to
collect information from States on the SNF administrator, director of
nursing, infection preventionist or medical director, four positions
required by regulations. States maintain these lists but rarely in a
readily accessible digital format and not in ways that can be easily
shared with CMS or other Federal agencies. As a result, rapid
communication of new information and guidance is not possible. If a
booster shot is required, communication with these four positions will
be critical.
Question. What lessons can be drawn from the experience of the CVS-
Walgreen Long-Term Care Partnership?
Answer. This partnership in many ways was an amazing success story.
In less than 3 months, a national program was created to distribute,
administer, and report on vaccine administration to more than 15,000
nursing homes and 30,000 other long-term care facilities, such as
assisted living.
One criticism is the delegation to States, which in some ways
helped, but mainly added confusion and overly complicated the program.
States decided when the program would start, which vaccine to use, and
if nursing homes should start first or simultaneously with assisted
living and other LTC facilities. This crated scheduling challenges.
Moreover, the lack of a database on the four professional positions
described above required collecting primary contact information for all
SNFs, which resulted in challenges reaching the individual if there
were any errors or typos. This resulted in difficulties for CVS and WAG
in contacting facilities to schedule clinics. Having an up-to-date
database on the four leadership positions (administrator, director of
nursing, infection preventionist and medical director) is desperately
needed at CMS. This of course will require funding to CMS to develop
and maintain such a database.
______
Question Submitted by Hon. Elizabeth Warren
Question. Private equity facilities own approximately 11 percent of
nursing homes nationwide.\10\ For years, reports have highlighted that
private equity owned facilities provide worse care than other nursing
homes. According to one 2014 study, private equity-owned facilities
generally ``deliver poorer quality of care'' than other chain-
affiliated for-profit facilities; are likely to try to reduce cost by
``substituting expensive but skilled RNs with cheaper and less skilled
nurses''; and ``report significantly higher number of deficiencies''
that climb with more years of private equity ownership.\11\ A study
released last month similarly showed found that private equity
ownership of nursing homes ``increases the short-term mortality of
Medicare patients by 10 percent, implying 20,150 lives lost due to
[private equity] ownership over [a] 12-year sample period.''\12\
Private equity ownership was also associated with ``declines in other
measures of patient well-being, such as lower mobility'' and taxpayer
spending-per-episode increases of 11 percent.\13\ Meanwhile, an
Americans for Financial Reform analysis of long-term care facilities in
New Jersey found higher rates of COVID-19 infection and death at PE-run
sites.\14\ However, it is challenging to identify specific ownership
structures of nursing homes based on existing CMS data.\15\
---------------------------------------------------------------------------
\10\ Skilled Nursing News, ``COVID-19 Brings Private Equity
Investment in Nursing Homes Into the Spotlight,'' Alex Spanko, March
19, 2020, https://skillednursingnews.com/2020/03/covid-19-brings-
private-equity-investment-in-nursing-homes-into-the-spotlight/.
\11\ Journal of Health Care Finance, ``Private equity ownership of
nursing homes: Implications for quality, June-July 2014,'' Rohit
Pradhan et al., October 2015, http://healthfinancejournal
.com/index.php/johcf/article/view/12.
\12\ National Bureau of Economic Research, ``Does Private Equity
Investment in Healthcare Benefit Patients? Evidence From Nursing
Homes,'' Atul Gupta, Sabria T. Howell, Constantine Yannelis, and
Abhinav Gupta, February 2021, https://www.nber.org/system/files/
working_papers/w28474/w28474.pdf.
\13\ Id.
\14\ Americans for Financial Reform, ``Report: The Deadly
Combination of Private Equity and Nursing Homes During a Pandemic,''
August 6, 2020, https://ourfinancialsecurity.org/2020/08/report-3-
private-equity-nursing-homes-coronavirus/.
\15\ Health Affairs, ``These Administrative Actions Would Improve
Nursing Home Ownership and Financial Transparency in the Post COVID-19
Period,'' Charlene Harrington et al., February 11, 2021, https://
www.healthaffairs.org/do/10.1377/hblog20210208.597573/full/.
Answer. AHCA represents more than 14,000 member facilities,
including both for-profit and not-for-profit nursing homes and assisted
living facilities. How many of these facilities are nursing homes? What
percentage of these facilities are owned or controlled by private
equity entities? For all nursing homes, what is the average percentage
of nursing home revenue that is spent on direct patient care? For the
private equity-owned or controlled facilities, what is the average
percentage of nursing home revenue that is spent on direct patient
---------------------------------------------------------------------------
care?
AHCA membership includes approximately 10,000 of the Nation's
15,000 nursing homes, 4,000 of the estimated 30,000 assisted living
communities, and 200 intermediate care facilities for individuals with
intellectual and development disabilities (ICF/ID). Among nursing
homes, we represent approximately two-thirds of for-profit facilities,
half of not-for-profit facilities, and half of government facilities.
We do not have information nor access to CMS PECOS data on number owned
or controlled by private equity. We also do not collect or calculate
the proportion of revenue spent on direct patient care.
______
Questions Submitted by Hon. Patrick J. Toomey
Question. Prior to the COVID-19 pandemic, I worked alongside my
Pennsylvania colleague Senator Casey to address the quality of care for
nursing homes residents. We were successful in pressing the Centers for
Medicare and Medicaid Services (CMS) to publicize both participants and
candidates affiliated with the Special Focus Facility (SFF) program,
which provides more frequent oversight of facilities that consistently
fail to meet Federal safety and care requirements.
Specific to this issue, Senator Casey and I reintroduced the
Nursing Home Reform Modernization Act (S. 782) on March 16, 2021, which
would expand the SFF program to ensure that all facilities nominated as
candidates for the program receive additional oversight. Our
legislation would also increase educational resources for
underperforming facilities and create an independent advisory panel to
inform CMS on how best to rank nursing home performance.
As you know, part of our bill would allow nursing homes to reinvest
their civil monetary penalties (CMP) to make improvements and remedy
the root causes contributing to consistent deficiencies. Financial
penalties can be an effective tool to incentivize compliance with
Federal requirements. However, if the ultimate goal is to help a
facility improve and keep residents in their homes--at what point do
the penalties make it more challenging for a consistently poor
performing nursing home to improve?
Answer. By the time a SNF finds itself on the Special Focus
Facility list, it has often had repeated citations but also CMPs over
the preceding two to 3 years. At this point, further citations and CMPs
are very unlikely to remedy the underlying problem. Also, at this
point, the facility needs to invest in additional resources which may
be staff, equipment, or environmental changes. Further citations and
CMPs would no longer be helpful at this point and would only make
matters worse. Having access to capital, like the money collected
through CMPs would remedy the situation by helping these facilities
acquire the resources needed to address underlying issues. The Care For
Our Seniors Act, a package of major reforms for the nursing home
industry we developed with LeadingAge, includes a proposal on how to
address chronic poor performing nursing homes (https://
www.ahcancal.org/Advocacy/Documents/Poor-Performing-Facilities.pdf).
Question. Can you describe a situation in which a poor-performing
nursing home and its residents would benefit from the facility being
able to reinvest its CMPs into quality improvement initiatives?
Answer. Facilities often find themselves on the SFF list due to
lack of staffing, equipment or outdated physical environment. Rural
facilities especially often need access to clinical expertise that is
not available, and the cost to upgrade to broad band Internet and offer
telemedicine are not possible without access to additional funds. This
is where access to the CMP funds would be helpful. Additionally,
chronically poor-performing facilities may need help addressing low
staffing levels, and CMPs funds could assist in recruiting caregivers
and offering them signing bonuses. Fundamentally, taking more resources
away from an already under resourced facility for whatever the reasons
does not make sense. Providing access to CMP funds or allowing further
CMPs to be used to reinvest in needed changes to remedy the root cause
leading to the chronic poor performance would help avoid closure of
these facilities.
______
Questions Submitted by Hon. John Barrasso
Question. Wyoming nursing facilities are mostly located in rural
and frontier communities. These nursing homes are often attached to a
rural hospital. These facilities provide training for Certified Nursing
Assistants (CNAs), which are the backbone of the nursing home
workforce. Through the years, nursing homes in my State have reported
they have lost the ability to train their own CNAs. According to an
article published in Health Affairs, this is because nursing homes with
a civil monetary penalty greater than $10,000 lose the ability to
conduct CNA training for 2 years. In rural communities, where the
nursing home is often the sole source of training for CNAs, this
creates a tremendous burden.
Please comment on the impact losing the ability to train CNAs has
on nursing homes.
Answer. Finding and recruiting staffing at all levels but
particularly among CNAs has become a greater and greater challenge.
Developing a training program has been an effective strategy to recruit
and retain CNAs. These programs require an investment in resources and
staff. However, current statutory language requires these training
programs to be suspended for 2 years for any citation resulting in
substandard quality or CMPs greater than $10,000. Even when the
facility has quickly remedied the situation leading to the CMP so that
they are in full compliance, the CNA program is suspended for 2 years.
This has not only resulted in the closure of many programs but also
inhibits many providers from investing in the creation of these
programs for fear of suspension. Once suspended, the ability to recruit
and train additional staff becomes even more challenging. Often more
staff are needed, yet the solution to the problem is hindered by this
statutory language.
Question. Can you provide suggestions on how to address this
situation, especially in rural communities?
Answer. It is understandable that a facility found to be seriously
out of compliance with Medicare or Medicaid standards should not be
training CNAs, but once the facility has remedied the situation and
attained substantial compliance, the suspension of the CNA program
should be lifted. This requires a change to the statute, which AHCA has
advocated for over the past several years. We would be happy to work
with your office and the Senate Finance Committee to address this
problem.
Question. A top concern of Wyoming nursing facilities is making
sure there are enough staff to care for residents. Many Wyoming nursing
homes provide professional development and other educational
opportunities to attract and maintain their staff.
Can you discuss solutions related to workforce development you
believe will improve the ability of nursing facilities to attract and
maintain direct care staff?
Answer. There are two principal challenges with recruiting and
retaining staff in nursing homes. First, there are not enough nurses
and other health professionals being trained in the Nation to meet the
needs of older adults seeking care from all types of providers,
including hospitals, physician offices, home health agencies, etc.
Second, hospitals and other provider settings are able to offer more
competitive wages and benefits as they are less dependent on Medicaid
funds. In SNFs, two-thirds of the residents are covered by Medicaid,
which MedPAC has shown under reimburses for the actual cost of care in
nursing homes. As a result, nursing homes cannot compete with hospitals
for nurses and other staff.
What is desperately needed is for Congress to provide additional
funding to nursing schools and other schools training our health-care
workforce but to make the funding tied to having graduates work in
long-term care. This is similar to funding to medical schools linked to
training primary care providers. Without this requirement, we have seen
new graduates seek employment in hospitals and other provider settings.
Another approach is to provide financial incentives to health-care
professionals to work in long-term care. Two mechanisms would include
loan forgiveness and tax incentives. Many graduates including nurses,
pharmacists, therapists and social workers graduate with enormous
student debt. Having loan forgiveness for each year working in long-
term care would help increase the workforce in nursing homes.
Similarly, tax credits to health-care professionals who work in long-
term care would also help.
There are other strategies we are happy to discuss with you and
your staff but these two approaches we believe are most effective. You
may also view more of our ideas to address workforce challenges in
long-term care through our specific proposal in our Care for Our
Seniors Act, a package of major reforms for the nursing home industry
we developed with LeadingAge (https://www.ahcancal.org/Advocacy/
Documents/Workforce-Strategies.pdf).
Question. An article in the March edition of Health Affairs points
out that although staff turnover is an important indicator of nursing
home quality, this has never been included on the Nursing Home Compare
website, maintained by Medicare.
Please discuss the impact of staffing turnover on the quality of
care provided in nursing homes.
Answer. Staff turnover has been shown to be associated with quality
outcomes in numerous academic studies. In fact, turnover has a stronger
association with quality outcomes than staffing levels. When staff
leave, it's hard to assure consistent compliance with policies and
procedures as you are always training new staff. Also, new staff are
less familiar with the residents and therefore, may miss subtle changes
in their condition that signify a problem. We have made staff turnover
and retention a center piece of the AHCA Quality Initiative but were
hampered by the lack of a Federal measure on turnover and retention.
Question. Specifically, do you believe turnover rates from nursing
homes should be made more readily available for public review?
Answer. Yes, AHCA has supported CMS moving to calculate and
publicly report staff turnover and retention. AHCA made turnover and
retention a core measure and goal of our Quality Initiative. We
believe, as the literature has shown, that turnover and retention are
more important measures than staffing levels.
Questions Submitted by Hon. Todd Young
Question. Workforce issues, including high staff turnover, have
been a longstanding issue for nursing homes. Research suggests that
high nursing staff turnover can have a negative impact on the quality
of care for residents; it has been connected with increases in patient
rehospitalizations and the use of physical restraints, and it can also
affect the spread of infections within nursing homes.
The COVID-19 pandemic has only exacerbated this problem. Nursing
homes lost nearly 10 percent of their workforce in 2020. And a
significant percentage of nursing homes nationwide--including nearly 16
percent in my State of Indiana--are still reporting shortages of
nursing staff.
Dr. Gifford, one of AHCA/NCAL's recommendations to governors early
on in the pandemic was to temporarily waive existing State regulations
and allow medical professionals to work across State lines. Are these
State licensing barriers something that could be streamlined or
otherwise addressed on a more permanent basis to respond to workforce
issues in nursing homes?
Answer. State licensing laws for physicians, nurses,
administrators, pharmacists, and other health-care professionals are
similar in concept but differ in specific details. This makes it
difficult for professionals moving from State to State. CMS used the
public health emergency to issue 1135 waivers allowing health-care
professionals who bill for and work in Medicare-certified facilities in
any State as long as they were licensed in good standing in one State.
However, this does not supersede State licensing requirements. During
emergencies such as a pandemic, natural disaster, etc. this limits the
ability of health-care professionals to cross State lines to help when
workforce shortages exist relative to the emergency.
Two potential solutions exist. First, each State as part of their
emergency preparedness plans should have model executive orders for
governors to waive State licensing restrictions to allow health care
professionals from other States to assist during the emergency. While
this need arises during nearly every emergency, such model orders are
not part of each State's emergency preparedness plans. Second, States
can participate in ``compact'' agreements that allow the easy
transition between States for individuals with licensure in good
standing. This may require State legislation to participate. Many
States have such agreements for nurses and physicians but not all.
Without such, States are reinventing the wheel to develop executive
orders and rushing to their State legislatures to get approval during
each emergency. This is not something that States should be waiting
until an emergency happens before addressing.
Question. How can the Federal Government better support
partnerships between nursing homes and academic entities whose
graduates may be interested in joining the long-term care workforce?
Answer. The Federal Government can emphasize the need for more
State cooperation in allowing health-care professionals with licensure
of good standing to move between States, particularly during
emergencies. Congress should link Federal emergency planning funding
and other Federal funding to making sure States have these programs in
place before emergencies happen.
Question. As outlined in many of your testimonies, the visiting
restrictions and isolation necessitated by the COVID-19 pandemic took a
heavy toll on the emotional and mental health of many nursing home
residents separated from their family members and other loved ones.
Fortunately, with increased vaccination and declining COVID-19 deaths,
many of these restrictions have been lifted.
While we hope that restrictions of this scale will not be necessary
again, it is worth examining ways to alleviate the negative emotional
and mental health effects that isolation may have on nursing home
residents. The use of technology, for one, has allowed residents to
interact virtually with family and other loved ones from whom they are
otherwise separated. Expanded use of telehealth has also helped
residents access routine health-care services while limiting spread of
the coronavirus.
What are some lessons learned from the public health emergency in
terms of the integration of technology in nursing homes--both in
helping residents visit virtually with loved ones and in accessing
health-care services?
Answer. Video-conferencing in nursing homes is a technology that we
need to build upon and expand. Prior to the pandemic, communication
with family and friends was challenging. In-person visitation often
only happened when family or friends lived close by and could travel.
Anecdotally, we hear that nearly half of residents never have in-person
visits due to family or friends living far away or their inability to
travel to the facility. The pandemic exposed this limitation when all
visitors were restricted.
The restriction of all visitors required the use of digital and
video technology which often does not exist in many long-term care
facilities due either to inadequate Internet infrastructure as well as
technological devices to support video conferencing. As a result, many
staff turned to their personal smart phones or tablets to help family
communicate with residents. CMS did allow facilities to apply for a
limited amount of funds from the CMP accounts to purchase equipment to
facilitate video conferencing. While this was helpful, it was woefully
inadequate and took substantial time to complete the application and
review process.
The use of telemedicine was critical during the pandemic. The risk
of spread of the virus increased with each human-to-human interaction.
Use of telemedicine allowed health-care professionals to provide care
to residents without being physically present. This was facilitated by
CMS waiving Medicare payment regulations through 1135 waivers; however,
these waivers will cease when the public health emergency expires.
There are benefits to telemedicine for patients even after the
pandemic. Bills such as S. 368, the Telehealth Modernization Act, led
by Senator Scott, would make those waivers permanent, and we support
this legislation.
Question. Do you anticipate this type of technology continuing to
be used beyond the pandemic?
Answer. Yes, I do. As mentioned, in-person visitation was often a
challenge prior to the COVID. The need for better and more frequent
communication between family members and friends is needed. The
familiarity and expansion in its use will likely continue after the
pandemic but will require building the appropriate infrastructure.
Many rural facilities have inadequate access to broadband Internet
to facilitate video conferencing. Communication at popular times of the
year, such as holidays, often overwhelms a facility's bandwidth.
Additionally, telemedicine can help provide life-improving care to
residents, especially in rural communities, where the availability of
health-care professionals is scarce. Telemedicine could help fill the
gap where workforce shortages exist. Also, the technology is
continually evolving and improving, and nursing homes do not always
have the resources to keep up with the latest technology even though it
could be beneficial to residents.
Congress should fund the expansion of Internet infrastructure
(bandwidth and Wi-Fi technology) to allow strengthen communication
between residents and their families and friends as well as further
develop telemedicine. The constant upgrading necessary to keep abreast
of the latest technology will also be critical to better patient care,
avoid problems over time, and prepare for the next emergency.
______
Questions Submitted by Hon. Maggie Hassan
Question. We have heard repeatedly from long-term care facility
workers that the lack of access to paid sick leave is keeping some
individuals from choosing to take the COVID-19 vaccine. Widespread
vaccinations within long-term care facilities is our most effective
tool in protecting workers and residents, so we must eliminate any
barriers that are impacting vaccine uptake at this critical time.
Approximately what percentage of your member facilities currently
provide paid sick leave to workers?
Answer. We do not have that information available among our
membership.
Question. Among those workers who receive paid sick leave, how many
hours does each worker receive annually?
Answer. We do not have that information available among our
membership.
Question. What additional paid sick leave policies have your member
organizations established for workers since the beginning of the COVID-
19 pandemic?
Answer. Anecdotally, we have heard many providers provided various
additional wages and benefits to staff including ``hero'' or bonus pay,
childcare, assistance programs for things like groceries, and paid time
off, whether to receive the vaccine or if they had to isolate due to
symptoms of or exposure to COVID.
Question. What additional paid sick leave policies have your member
organizations established for workers the relationship between access
to paid leave and COVID-19 vaccination rates became apparent?
Answer. As mentioned above, we have heard anecdotally that
providers provided paid time off to staff to receive the COVID-19
vaccine if they were unable to attend one of the three on-site clinics
offered at the facility by CVS or Walgreens. Similarly, we heard they
offered paid time off should they develop any symptoms following the
vaccine that limited their ability to work.
Question. In addition to being an important near-term protection
during the COVID-19 pandemic, do you believe that widespread access to
annual paid sick leave for workers in long-term care facilities would
reduce the prevalence of influenza and other illnesses that pose risks
to residents in these facilities?
Answer. AHCA does not have information on paid sick leave for our
members. Health insurance and paid sick leave are important for all
workers in the country including health-care workers but are not always
consistently offered to employees. Efforts to provide paid sick leave
should also be coupled with increase childcare services for long-term
care health-care workers. These would help with control of infectious
outbreaks, epidemics and pandemics. We would support efforts by
Congress to make these services available and affordable to health-care
workers and other staff who provide vital services in nursing homes.
It is important to keep in mind that all health-care settings,
especially long-term care, must delicately balance ensuring that there
are enough caregivers to properly aide residents and patients, while
also making sure sick employees do not create unnecessary, additional
risks to residents. This means we need additional support to help
prevent workforce shortages and that long term care receives the
necessary resources to further invest in their staff.
We have been calling for help with the long-term care workforce
shortage and chronic underfunding of nursing homes for years. If
policy-makers wish to expand paid sick leave or other benefits to
health-care workers, we also need your support in funding such benefits
and in recruiting more caregivers to long-term care. Our Care for Our
Seniors Act (www.ahcancal.org/solutions) offers meaningful proposals to
address workforce and funding challenges that could help encourage more
providers to offer or expand pick sick leave benefits.
Questions Submitted by Hon. John Cornyn
Question. We've heard from nursing homes and long-term care
facilities that experienced difficulty staying up to date with public
health guidance as they were released. You've noted the challenge of
guidance being outdated by the time they were released.
Did AHCA members experience issues with guidance coming from State
and local public health officials conflicting with CDC and CMS
guidance? What recommendations do you have to improve the process of
new guidance being pushed out to congregate care providers?
Answer. While CMS and CDC worked at unprecedent pace to issue new
guidance, it was still often slow and outdated by the time it was
issued, often due to this being a novel coronavirus. In some
circumstances, the clearance process delayed issuing of guidance
further. Notice that Federal guidance was forthcoming was not
consistently shared or was misstated due to clearance delays that took
longer than anticipated. As a result, States stepped in to develop
their own guidance which invariably would conflict with Federal
guidance when issued and/or conflict with other States' guidance. This
added to confusion among providers.
The linking of guidance to strict enforcement actions also
exacerbated the challenges. Facilities using a ``good faith'' effort to
follow guidance would find themselves being cited for non-compliance.
This led providers to ask for detailed guidance for every scenario,
which further bogged down the Federal agencies. Further complicating
the confusion was the fact that the multitude of guidance was located
on multiple different webpages and issued by numerous agencies. Also,
early on changes to guidance documents and webpages were made without
any notation, making it hard to locate changes and ensure providers
were accessing the most updated version. CDC eventually added a date
indicating when the webpage was last updated and provides a short
summary of the changes made at the top of the page. This has been
extremely helpful.
Guidance is needed from the Federal agencies. It needs to be issued
quickly and located in a centralized location--ideally on single page
encompassing guidance from all relevant agencies. Notations need to be
made on any changes being made to existing guidance that is updated.
CMS continues to issue its guidance in QSO memos, and one cannot find a
single page pulling together all the guidance in one place.
Strict enforcement needs to be limited to those who are blatantly
non-compliant. Those who are aware of the guidance and making a good
faith effort to comply but may be doing not as intended should not be
cited, fined, or sued.
Question. AHCA called for reforms to Medicaid reimbursement to
adequately fund care in nursing homes. Can you elaborate on what steps
you believe are necessary to improve care for residents?
Answer. For years, nursing homes have been underfunded by Medicaid,
significantly impacting their ability to invest in their workforce,
clinical practices, and infrastructure. COVID-19 exacerbated these
financial challenges, as the industry has dedicated tens of billions of
dollars to fight the virus with PPE, testing and additional staff
support. This pandemic has pushed nursing homes to the financial brink,
and more than 1,000 facilities are in danger of closing this year,
threatening access to long-term care for vulnerable seniors and
individuals with disabilities. With 60 percent of residents relying on
Medicaid for their daily care, the program must fund nursing homes for
the actual cost it takes to provide high-quality care.
To address chronic Medicaid underfunding, AHCA and LeadingAge
propose the following short and long-term investment strategies for
nursing homes through our Care for Our Seniors Act (www.ahcancal.org/
solutions):
Enhanced FMAP (EFMAP) to States to for the mandatory nursing
facility benefit with requirements that additional Federal funds be
used for nursing facility (NF) rates. Additions to NF rates will cover
the costs of new quality and clinical provisions to improve patient
care and staff safety;
Federal Framework for ``Allowable Cost'' or ``Reasonable Cost''
would establish Federal guidelines for State allowable cost
definitions. Currently, State definitions of ``allowable cost'' vary
widely and, without a Federal framework, will continue to limit
Medicaid reimbursable care and other nursing facility costs.
Specifically, AHCA would require States to cover 100 percent of costs
up to the 90th percentile; and
Medicaid Rate Adequacy Requirement that rates are brought up to
the cost of care and, subsequently updated regularly to keep pace with
increases in costs of care. Currently, Medicaid contains no requirement
that Medicaid rates be updated to keep pace with increases in the cost
or care, ensuring quality or administrative burden. Under AHCA's
proposed policy, States would undertake a two-step process: (1) conduct
a cost of care study comparing market costs and reimbursement with
Medicaid reimbursement levels and increase reimbursement to the new
``allowable cost'' benchmark; and (2) conduct a Medicaid rate update
and rebase annually replicating step one, above.
Additionally, AHCA proposes that States be required to form a
Nursing Facility Value-Based Purchasing (VBP) Committee. State Nursing
Facility VBP Committees would be charged with developing a State-
specific Nursing Facility VBP Design Concept which must be submitted to
CMS 2 years after the end of the Public Health Emergency.
______
Questions Submitted by Hon. James Lankford
Question. There has been heightened discussion about the nursing
home survey process regarding what it accomplishes and perhaps what it
misses.
What is your opinion on the current process, and what do you think
can be done to ensure better resident care?
Answer. The current nursing home survey process is not serving
residents' best interests. The goal of the nursing home survey process
is to assure basic levels of quality and safety for all patients,
residents and clients receiving care from Medicare and Medicaid
certified providers. However, the same modes of citation and penalty
have been used for decades and have not evolved to reflect the science
of quality improvement nor a current understanding of how to
effectively use oversight to create change and achieve desired
outcomes. The punitive nature of the process continues to drive good
staff members and leaders out of long-term care and into other health-
care jobs where the oversight process focuses on supporting a culture
of safety and continuous quality improvement. Multiple stakeholders--
including nursing home staff, consumer advocates, Congress, and CMS--
are dissatisfied with the survey and enforcement process and results.
For instance, the same top issues are cited year after year, which
shows that the current oversight process is not successfully driving
improvements in these areas as it is meant to do. At the same time,
with more than 200 distinct citations or ``F-tags'' that may be issued,
half are cited less than 1 percent of the time. This shows the survey
process is trying to measure too many things and is not focused on the
most important areas impacting resident care.
In addition, the current survey process does not effectively
identify providers' systemic strengths and weaknesses, nor are these
strengths and weaknesses communicated clearly and effectively to
consumers. The survey and enforcement process centers around inspection
and control which is not driving improved results for quality of care
and quality of life for residents. The impact and success of the
survey/regulatory system is frequently measured by rates of penalties
imposed and performing more frequent surveys, rather than by the
quality improvements that have been achieved and sustained through the
oversight process. This approach makes it difficult for providers to
correct problems and sustain compliance while preventing consumers from
making more informed choices that also help drive quality improvement.
Within this system, CMS spends much of its survey budget on
addressing poor performing nursing homes, yet the current process and
use of resources is not effective in improving care among struggling
providers. At the same time, too much time is spent on surveying
providers that are consistently high performers. The extensive
investment of time, money and energy by State survey agencies, the
Federal Government, nursing home staff as well as other stakeholders in
the survey process is not delivering an equal or better return on
investment to benefit the residents the system is intended to serve.
The goal of the survey process should be to get as many providers
to be in substantial compliance all the time. AHCA recommends a more
modern, efficient, and effective survey process that focuses on what
matters most to residents to support high quality of care and quality
of life. This includes reforming the survey process based on
understanding when citation and enforcement is helpful in driving
compliance andimprovement and when it is important to recognize and
support providers' good faith efforts; implementing changes to better
help turn around chronic poor performing nursing homes; and adding
customer satisfaction to the Five-Star rating system to help monitor
the quality of a facility for family members and guidance consumer
choice.
AHCA and LeadingAge's Care for Our Seniors Act outlines these
proposed reforms to the oversight system (www.ahcancal.org/solutions).
Question. Do you think that adding customer satisfaction
information to the ``nursing home compare'' website may be helpful in
providing accountability?
Answer. Yes, customer satisfaction should be added to Nursing Home
Compare. Customer satisfaction is well-excepted and a critical type of
quality measure. Nursing homes are the only Medicare provider that does
not have customer satisfaction collected and publicly reported by CMS.
During the pandemic, we have heard of the importance of communication
with family and residents about what is happening. We believe one way
to examine how facilities responded would have been to collect
satisfaction data but unfortunately, despite our repeated calls for
this information to be collected and reported, this has not happened.
AHCA and LeadingAge included adding customer satisfaction to
Nursing Home Compare among our many reform proposals in the Care for
Our Seniors Act (https://www.ahcancal.org/Advocacy/Documents/Customer-
Satisfaction.pdf).
______
Prepared Statement of R. Tamara Konetzka, Ph.D., Louis Block Professor,
Department of Public Health Sciences, Biological Sciences Division,
University of Chicago
Chairman Wyden, Ranking Member Crapo, and distinguished members of
the committee, thank you for the opportunity to testify today on the
topic of COVID-19 in nursing homes.
My name is Tamara Konetzka. I am a professor of health economics
and health services research at the University of Chicago. I have been
conducting research on long-term and post-acute care for more than 25
years. I have led numerous studies that examine the quality of nursing
home care and how public policy might improve it, how Medicare and
Medicaid policy influence care access and quality, and how increasing
provision of services in home- and community-based settings impacts
health. I serve on the technical expert panel that advises the Centers
for Medicare and Medicaid Services on the Nursing Home Compare 5-star
rating system that publicly reports nursing home quality.
Almost 40 percent of all COVID-19 deaths in the United States have
been linked to long-term care facilities.\1\ The scope of this problem
became apparent early in the pandemic, generating widespread media
attention and public alarm. Almost a year ago, a New York Times article
referred to nursing homes as ``death pits,''\2\ due to seemingly
uncontrollable COVID-19 spread within these facilities. This
devastation continued during subsequent surges.\3\
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\1\ About 40 percent of U.S. Coronavirus Deaths Are Linked to
Nursing Homes. The New York Times. 2020.
\2\ Stockman F., Richtel M., Ivory D., Smith M. ``They're Death
Pits'': Virus Claims at Least 7,000 Lives in U.S. Nursing Homes. New
York Times. April 17, 2020.
\3\ Konetzka R.T., Gorges R.J. Nothing Much Has Changed: COVID-19
Nursing Home Cases and Deaths Follow Fall Surges. J Am Geriatr Soc.
2020.
The circumstances that led to this tragedy, often referred to as a
``perfect storm,''\4\ start with the attributes of the novel
coronavirus itself. The coronavirus that causes COVID-19 is airborne,
can be spread asymptomatically, and is particularly dangerous for older
adults with underlying health conditions. It is therefore no surprise
that nursing home residents, with their demographic and clinical
profile, suffered disproportionately high rates of cases,
hospitalizations, and deaths.
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\4\ Ouslander J.G., Grabowski D.C. COVID-19 in Nursing Homes:
Calming the Perfect Storm. J Am Geriatr Soc. 2020.
The nursing home setting exacerbates this risk. Many facilities
house, in close quarters, dozens or sometimes hundreds of residents who
require hours of hands-on care on a daily basis. Many residents share
rooms with others. Physical distancing is extremely difficult given the
realities of congregate care settings. Finally, asymptomatic spread
means that residents and staff can cause an outbreak without knowing
it. This was especially lethal early in the pandemic when there was
less known about asymptomatic transmission and less widespread testing
---------------------------------------------------------------------------
of asymptomatic individuals.
At long last, there is cause for optimism. Overall COVID-19 cases
and deaths have declined nationwide in recent months.
The sharpest declines are occurring in nursing homes. The weekly
number of new COVID-19 cases and deaths in nursing homes are at their
lowest since national data collection began last May. Reported deaths
among nursing home residents have declined by more than 80 percent
since the new year. It is still difficult at this early date, and
without the necessary data, to rigorously assess the causes of the
decline.
We do know that the vast majority of nursing home residents have
been vaccinated. This has almost certainly played a large role. Trends
in nursing home cases and deaths, after closely matching trends in
community cases and deaths throughout the pandemic, started to diverge
mid-January, when a much higher percent of nursing home residents had
been vaccinated than community residents.
[GRAPHIC] [TIFF OMITTED] T1721.027
.epsIncreased vaccination and declining COVID-19 deaths have
brought other physical and emotional benefits for nursing home
residents. These made possible new CDC/CMS recommendations that nursing
homes fully open to visitors, a hugely important development for
residents and their families.
Despite this welcome progress, there remains need for caution, and
particularly the need to resist complacency. First, not all residents
and staff are vaccinated. Whereas most nursing home residents were
eager to be vaccinated, take-up has been much lower among staff, by
some reports 37 percent.\5\ Second, many facilities face high staff and
resident turnover. This dynamic will produce declining vaccination
rates in many facilities over time without ongoing efforts. Third,
COVID-19 infection is still possible after vaccination, a risk that may
increase with new coronavirus variants. If the U.S. experiences a new
surge in cases this spring as public health measures are relaxed, it
will provide a real test of the effectiveness of vaccination efforts in
nursing homes in avoiding the new surge.
---------------------------------------------------------------------------
\5\ Gharpure R., Guo A., Bishnoi C.K., et al. Early COVID-19 First-
Dose Vaccination Coverage Among Residents and Staff Members of Skilled
Nursing Facilities Participating in the Pharmacy Partnership for Long-
Term Care Program--United States, December 2020-January 2021. MMWR Morb
Mortal Wkly Rep. 2021;70(5):178-182.
Even if vaccination proves to be wildly successful, there is still
much to be learned from this pandemic to help prepare for the next one.
evidence on predictors of nursing home cases and deaths
Policy-makers and researchers alike have examined attributes of
nursing homes associated with better and worse outcomes from the
pandemic, looking for clues as to organizational best practices,
opportunities for intervention, and where to assess blame. The results
are clear and consistent, and not what many expected. A large body of
evidence, some produced by our team at the University of Chicago \6\
and some by others, shows that the two strongest and most consistent
predictors of worse COVID-19 outcomes are nursing home size, with
larger facilities being more at risk, and COVID-19 prevalence in the
surrounding community. Given an outbreak, nursing homes in the highest
quintile of community prevalence averaged five more deaths per facility
than similar nursing homes in the lowest quintile.
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\6\ Rebecca J. Gorges was my collaborator on this research. I also
thank Xiaoxuan (Stephen) Yang for research assistance.
Related studies examined the role of staff in inadvertently
bringing the virus into nursing homes. One analysis used cell phone
data to track staff movements in and out of facilities \7\ and another
examined the ZIP codes where nursing home staff live;\8\ they found
that staff traffic between facilities and in and out of areas with high
virus prevalence was associated with more cases and deaths in the
nursing homes where they worked. Nursing assistants in nursing homes
usually work for minimum wage, few or no benefits, and no sick leave.
To make ends meet, they often work multiple jobs in multiple
facilities.\9\, \10\ Without sick leave, staff may have felt
compelled to work even when symptomatic or after a COVID-19 exposure.
These conditions likely exacerbated the risk of outbreaks.
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\7\ Chen M.K., Chevalier J.A., Long E.F. Nursing home staff
networks and COVID-19. Proc Natl Acad Sci U S A. 2021;118(1).
\8\ Shen K. Relationship between nursing home COVID-19 outbreaks
and staff neighborhood characteristics. medRxiv preprint. 2020.
\9\ Baughman R.A., Stanley B., Smith K.E. Second Job Holding Among
Direct Care Workers and Nurses: Implications for COVID-19 Transmission
in Long-Term Care. Med Care Res Rev. 2020:1077558720974129.
\10\ Van Houtven C.H., DePasquale N., Coe N.B. Essential Long-Term
Care Workers Commonly Hold Second Jobs and Double- or Triple-Duty
Caregiving Roles. J Am Geriatr Soc. 2020;68(8):1657-1660.
Equally important are nursing home attributes that are not linked
with COVID-19 outcomes. Multiple rigorous studies have found no
meaningful association between COVID-19 outcomes and standard nursing
home quality metrics--usually measured by the Nursing Home Compare star
ratings.\11\-\14\ (Studies that did find an association
often failed to control for community virus prevalence or had very
small samples.) Beyond the star ratings, several studies examined
specific and salient aspects of quality such as prior infection control
citations. Perhaps surprisingly, these were also not associated with
poor COVID-19 outcomes.\11\, \15\
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\11\ Abrams H.R., Loomer L., Gandhi A., Grabowski D.C.
Characteristics of U.S. Nursing Homes With COVID-19 Cases. J Am Geriatr
Soc. 2020.
\12\ Chatterjee P., Kelly S., Qi M., Werner R.M. Characteristics
and Quality of U.S. Nursing Homes Reporting Cases of Coronavirus
Disease 2019 (COVID-19). JAMA Network Open. 2020;3(7):e2016930.
\13\ Dean A., Venkataramani A., Kimmel S. Mortality Rates From
COVID-19 Are Lower In Unionized Nursing Homes. Health Aff (Millwood).
2020;39(11):1993-2001.
\14\ Gorges R.J., Konetzka R.T. Staffing Levels and COVID-19 Cases
and Outbreaks in U.S. Nursing Homes. J Am Geriatr Soc. 2020.
\15\ White E.M., Kosar C.M., Feifer R.A., et al. Variation in SARS-
CoV-2 Prevalence in U.S. Skilled Nursing Facilities. J Am Geriatr Soc.
2020.
Such results do not imply that we should ignore traditional nursing
home quality and infection control measures. Rather, they suggest that
high quality and good infection control are not enough. The reality is
that staff enter and leave daily. When COVID-19 is prevalent in
surrounding communities, even nursing homes that are of high quality
and that implement recommended infection control procedures remain at
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risk.
The numbers bear this out. At this point, more than 99 percent of
nursing homes in the Nation have had at least one COVID-19 case among
residents or staff. More than 80 percent have had at least one COVID-19
death. This is not a ``bad apples'' problem, and no subset of nursing
homes has found a magic bullet to keep the virus out. Despite the
emergence of best practices and regulatory inspections for infection
control, nursing home cases and deaths closely matched trends in
community cases and deaths not only in spring but throughout the summer
and fall surges.
This reality underscores a key oversight and lesson of the past
year. Many of us have been asking: What should nursing homes be doing
differently? How can they do better? Alongside these questions, we must
ask with equal urgency: What should our entire communities be doing?
Put differently: The single most important thing we could have done as
a Nation to reduce the tragedy in nursing homes over the past year was
to use public health measures to control the spread of the virus in the
general population. That will be true this coming year, as well.
racial disparities in nursing home cases and deaths
It is now well-known that the pandemic has disproportionately
harmed communities of color. Disparities in COVID-19 cases and deaths
are also clear in the nursing home sector. We recently examined these
differences in nursing homes nationwide, in a study published in JAMA
Network Open.\16\ Because we lacked individual-level data, we focused
on the racial distribution of residents in each facility, categorizing
nursing homes by the percent of residents who are white. The
differences are striking: Nursing homes serving more (>40 percent) non-
white residents experienced more than three times as many COVID-19
cases and deaths as those serving primarily white residents.
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\16\ Gorges R.J., Konetzka R.T. Factors Associated With Racial
Differences in Deaths Among Nursing Home Residents With COVID-19
Infection in the U.S. JAMA Netwrk Open. 2021;4(2):e2037431.
In unpacking the reasons for such disparities, we found that race
was correlated with two strong predictors of COVID-19 outcomes, nursing
home size and COVID-19 prevalence in the surrounding community. Non-
white residents are more likely to live in larger facilities in
neighborhoods where COVID-19 is prevalent. They face correspondingly
greater risk of becoming infected or dying from COVID-19. Of note,
although non-white residents tend to be in lower-quality nursing homes,
these quality differences do not appear to explain disparities in
COVID-19 outcomes, consistent with the broader research I described
above. And although our measures of facility case-mix were limited,
facility differences in residents' prior underlying health do not
---------------------------------------------------------------------------
appear to explain COVID disparities, either.
As we consider ways to reduce risk and improve outcomes for COVID-
19 and for future public health threats, reducing these disparities by
race should be a prominent goal.
the importance of staffing
The key predictors of nursing home cases and deaths--size and
location--leave little room for immediate and direct intervention by
nursing homes themselves. Our team took a nuanced look at the role of
staffing using national data, in the hope of identifying factors that
might be more under the control of nursing homes and more amenable to
policy changes. Other researchers have found complementary results in
smaller studies.\17\, \18\
---------------------------------------------------------------------------
\17\ Figueroa J.F., Wadhera R.K., Papanicolas I., et al.
Association of Nursing Home Ratings on Health Inspections, Quality of
Care, and Nurse Staffing With COVID-19 Cases. JAMA. 2020;324(11):1103-
1105.
\18\ Li Y., Temkin-Greener H., Shan G., Cai X. COVID-19 Infections
and Deaths Among Connecticut Nursing Home Residents: Facility
Correlates. J Am Geriatr Soc. 2020;68(9):1899-1906.
In the often-contentious world of nursing home policy, it is
difficult to find things that everyone agrees on--researchers, policy-
makers, advocates, and nursing homes themselves. Here's one thing
everyone agrees on: On average, nursing homes lack sufficient numbers
of staff to provide the quality care we would all want to receive.
Having enough staff is arguably the single most important element in
delivering high-quality care. Providing hands-on assistance to
residents is at the heart of what nursing homes do. A large body of
---------------------------------------------------------------------------
research confirms the importance of staffing to nursing home outcomes.
It became clear during the pandemic that having enough staff was
critical to implementation of best practices in preventing or
containing COVID-19 outbreaks. These staffing-intensive practices
include: testing of all residents, the physical separation of COVID-
positive and COVID-negative residents, and the assignment of dedicated
staff to each group to avoid traffic between the two. At the same time,
the ability of nursing homes to attract and retain sufficient staffing
has been exacerbated by the pandemic: Staff were getting sick with
COVID. Others were afraid of becoming infected, or of bringing the
virus home to families, especially in the absence of adequate PPE. Some
staff members had to stay home with children who were suddenly learning
online. And it was difficult to find new staff to hire, for these same
reasons and due to competition with hospitals for additional health
care personnel. In the week ending February 21st, almost 17 percent of
nursing homes reported a shortage of staffing.
We specifically examined whether nursing homes that had higher
staffing ratios just prior to the pandemic had better COVID-19
outcomes. Having more staff did not reduce the probability of an
initial outbreak. However, higher baseline staffing ratios were helpful
in stemming an outbreak once it started: Nursing homes with the highest
staff hours per resident-day experienced fewer cases and deaths than
those at the bottom of the distribution. I should note that the effects
of staffing are dwarfed by the effects of community spread,\14\ but
increasing staffing represents a clear intervention that could improve
care and can save lives, during the pandemic and beyond.
recommendations
My research and the experiences in which I have been immersed for
the past year suggest several policy recommendations moving forward:
1. First, CMS policies implemented during the past year that aim
to ``incentivize'' nursing homes to handle the pandemic well (rewarding
facilities that have few deaths and/or fining those that have many) are
misguided. Some of these policies are valuable long-term strategies to
encourage quality improvement. These are not appropriate in the midst
of a crisis, particularly given the loose connection between nursing
home actions and COVID-19 deaths. At the time of an outbreak, what is
needed is not incentives or blame but rather assistance, especially to
those facilities that are struggling with outbreaks and may be
experiencing shortages of PPE, lack of access to rapid testing, or
insufficient staffing. I therefore strongly support the allocation of
American Rescue Plan funds to States for ``strike teams'' to rapidly
fill these gaps during an outbreak.
2. Second, we must provide greater assistance to large facilities
in communities of color. Such facilities do not typically earn
performance bonuses. If we are not careful, incentive policies intended
to promote best practices will instead exacerbate racial and ethnic
disparities by depriving under-resourced facilities--and thus their
patients and staff--of critically needed resources. All policies need
to be evaluated in the light of equity concerns.
3. Third, data collection and wide availability are essential to
assemble an accurate evidence base, to rapidly mobilize the clinical
and policy research community, and to formulate effective policy. We
would not have the evidence I discussed today without the data Congress
mandated that the CDC and CMS collect and disseminate beginning last
spring. Large gaps remain. Researchers cannot access facility-specific
data on vaccination dates and rates or COVID-19 cases and deaths by
race within nursing homes. This precludes rigorous analyses of the
effects of vaccines, for example, or a patient-level analysis by race.
Consumers who are considering nursing home care also have a right to
know what percent of residents and staff have been vaccinated. These
data need to be made available quickly.
4. Fourth, the COVID-19 pandemic underscores both the necessity
and the limitations of traditional infection control measures and
metrics. The American Rescue Plan puts substantial emphasis and funding
into improving nursing home infection control practices. It is clear
that these practices have been neglected and must be improved. At the
same time, this is a solution to a relatively narrow set of problems, a
solution that would not have avoided the tragedy of the past year. This
brings me to my final and arguably most important recommendation.
5. Fifth, direct-care staffing in nursing homes needs to be
increased. Even perfect infection control procedures will not improve
safety of nursing home residents without the staff to implement them.
In addition to low pay and few benefits, the job of direct-care nursing
home staff is difficult, often dangerous, and emotionally and
physically taxing. Add the risk of a potentially fatal infectious
disease, and it's amazing they show up and that they stay. Addressing
these challenges requires resources.
Despite broad agreement that nursing home understaffing is a
problem, there is less agreement about the root causes, and from where
the resources should come. Many argue, and I largely agree, that
America's long-term care system is underfunded. Nursing homes that rely
on Medicaid cannot afford to increase staffing without additional
reimbursement. At the same time, the dominance of for-profit ownership,
the growing role of private equity, cross-subsidization from Medicare,
and complex ownership arrangements such as related-party transactions
make it difficult to see where taxpayer money is being spent, and what
profit margins truly are. Greater transparency about these ownership
structures is urgently needed. We only know that under current
structures, the problem of understaffing has existed for decades;
something is not working.
In the short run, understaffed nursing homes cannot solve their
shortages when faced with a COVID-19 outbreak. They need direct help in
the form of strike teams. In the long run, resolving and moving beyond
the debate about root causes of understaffing to improve these jobs and
actually increase staffing is essential. This is, admittedly, a much
harder problem to solve, but it is an essential one. We can't forget
about this problem when the current pandemic is contained. We will
never achieve adequate nursing home quality unless we find a way to
attract and support the workforce providing the hands-on care.
Addressing this challenge is the best way to honor the memory of more
than 1,900 nursing home workers and more than 130,000 nursing home
residents who have died from COVID thus far. We can't turn back the
clock to prevent the tragedy of the past year. We can at least take
steps to learn from it.
Thank you for this opportunity to share my thoughts and expertise
on the critical issue of the tragedy of the COVID-19 pandemic in
nursing homes.
______
Questions Submitted for the Record to R. Tamara Konetzka, Ph.D.
Questions Submitted by Hon. Ron Wyden
Question. The Centers for Medicare and Medicaid Services (CMS)
issued an interim final rule last year that required nursing homes to
report COVID-19 data to the Centers for Disease Control and Prevention
on a weekly basis beginning May 17, 2020. These data included COVID-19
infections, COVID-19 deaths, and the availability of key equipment and
workers at individual nursing homes. The data have proved to be helpful
for the public, policy-makers, and industry stakeholders to track the
pandemic, and related issues, in these care settings. However, to date,
CMS has not required nursing homes to provide such data prior to May 8,
2020, despite calls from Senate Democrats to do so. In September 2020,
the Government Accountability Office (GAO) noted that ``by not
requiring nursing homes to submit data from the first 4 months of 2020,
HHS is limiting the usefulness of the data in helping to understand the
effects of COVID-19 in nursing homes.'' GAO went on to recommend that
``HHS, in consultation with CMS and CDC, develop a strategy to capture
more complete data on COVID-19 cases and deaths in nursing homes
retroactively back to January 1, 2020.''
Do you support GAO's recommendation? Why or why not? Please briefly
explain.
Answer. I support GAO's recommendation. Having accurate data is
essential not only to fighting a pandemic but to analyzing which
practices and policies worked and which did not. I note that the issue
is not only that nursing homes were not required to report COVID-19
cases and deaths prior to May 8, 2020, but that they were not required
even to specify whether they were including those earlier cases and
deaths; thus, we cannot distinguish true zeroes from missing data.
Analyses to date have had to make assumptions about how to handle those
early months. Rigorous analyses based on more accurate data will help
to fight the remaining challenges of this pandemic and to prepare
better for the next one.
Question. Residents and loved ones deserve to know whether a
nursing home is safe when deciding where to receive their care. Such
knowledge is more needed now than ever with the additional risk of
COVID-19. The Five-Star rating system was created to do just that--
provide clear and meaningful information on the quality of nursing
homes. The recent story in The New York Times (``Maggots, Rape and Yet
Five Stars: How U.S. Ratings of Nursing Homes Mislead the Public,''
March 13, 2021) was the latest evidence that this system needs to be
fundamentally rethought. In many cases, research has shown that a
facility that receives the system's top ratings does not necessarily
provide better care or protection for nursing home residents when
compared to lower-rated homes. Nursing homes may be able to game
certain quality measures to keep or achieve high ratings while
providing substandard care.
What changes do you recommend to the Five-Star system so it will
better reflect patients' outcomes of care and inform residents and
loved ones about the quality and safety of nursing homes?
Answer. I would like to start by pushing back a little against this
characterization of the Five-Star system and adding some clarity about
the evidence. While the system is certainly flawed and in need of
constant refinement, I also believe it has substantial face validity.
On average, 5-star nursing homes are significantly better than 1-star
or 2-star homes in meaningful ways. Bad things sometimes happen in very
good facilities, and some of the measures are susceptible to gaming,
but this does not mean the entire rating system is fundamentally bad.
After almost 2 decades of studying public reporting of nursing home
quality, I can say that I would use (and have used) the Five-Star
system myself to help choose a nursing home for family members. It
should always be just a starting point for in-person visits and
discussion.
That said, I agree that improvement is needed. I recently published
a review of the evidence on Nursing Home Compare and the Five-Star
system (Konetzka et al., 2020). We concluded that two key areas of
quality are completely missing from Nursing Home Compare (now Care
Compare) and should be added: (1) measures of resident experience and
quality of life; and (2) end-of-life care. Although improved safety is
critical, the lack of attention to quality of life is arguably a much
more important problem both in practice and in terms of what we measure
and report. For long-stay residents, the nursing home is where people
live, and yet our current system of measurement focuses solely on
physical health. To the existing measures of physical health and safety
I would also now add the need for reporting of COVID-19 vaccination
rates among residents and staff; prospective residents need to know
those rates in order to assess their risk.
In terms of the accuracy of what is already reported, there are
some issues to be solved. The most important component of the Five-Star
rating is the inspection score, derived from State Medicare/Medicaid
surveys for regulatory compliance. Although there are known problems
with the survey system, it is considered the most objective because it
is not based on facility-reported data. Suspicions of gaming usually
focus on the staffing and the quality measures components. Our research
shows nuanced evidence about this problem; blatant gaming exists, but
the measures also lead to some true quality improvement (Davila et al.,
2020; Konetzka et al., 2020; Perraillon et al., 2017). The Centers for
Medicare and Medicaid Services (CMS) has made several key improvements
in recent years to try to minimize gaming. In particular, the flawed
data system for collecting staffing data was replaced with a more
reliable and detailed payroll-based journal system, and several quality
measures were added that are based on Medicare claims data rather than
facility-reported assessment data. These have reduced, though not
eliminated, the opportunities for gaming.
I think of quality measurement and reporting as an ongoing process
of refinement; we will never reach a point where we think we have an
ideal system. In terms of priorities in order to best inform consumers
about the quality and safety of nursing homes, the addition of resident
experience measures would address the most glaring problem with
usefulness of the Five-Star system.
Question. Many stories of poor quality, abuse, and neglect in
nursing homes start and end with chronic understaffing. This is an
issue that has existed for decades and has yet to be adequately
addressed. In recent years, more than half of facilities had lower
staffing levels than those recommended by experts, and 75 percent of
nursing homes almost never met staffing levels required by CMS.\1\ The
COVID-19 pandemic has exacerbated these existing issues, with nursing
homes experiencing severe staffing shortages. Additionally, research
shows that Black Medicare beneficiaries are more likely to be admitted
to the lowest-quality nursing homes, which have lower ratios of nurses
to residents.
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\1\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7328494/.
In your written and oral testimony, you spoke about the impact of
staffing on quality of care and the racial disparities in quality of
---------------------------------------------------------------------------
care.
Would additional staffing requirements for Medicare, Medicaid, and
certified nursing homes help to reduce racial disparities in the
quality of care in these facilities?
Answer. We know from research that nursing home residents of color
are more likely to be in low-quality nursing homes with the lowest
staffing ratios (Konetzka and Werner, 2009; Mor et al., 2004). So, to
the extent that additional staffing requirements are most binding for
those facilities and succeed in raising the floor for minimal staffing,
these requirements will directly help to reduce racial and ethnic
disparities in the quality of nursing home care.
Question. What specific actions should Congress and/or CMS take to
ensure that nursing facilities have a level of overall staffing that is
concurrent with high quality care?
Answer. There are multiple possible ways to increase staffing in
nursing homes. The most direct way is to mandate minimum staffing
ratios that are substantially higher than current ratios. This will
likely necessitate an increase in Medicaid reimbursement in order to
cover the additional costs of hiring more staff and paying them more,
based on two premises: (1) current Medicaid reimbursement is too low to
make meaningful changes to staffing ratios; and (2) meaningful
increases in hiring will be difficult without an expanded workforce,
and that expansion would require more attractive compensation
(including higher wages, sick pay, and some benefits including health
insurance).
Several caveats apply to the need for higher reimbursement to
increase staffing. First, the lack of transparency in the use of
taxpayer dollars by nursing homes currently makes it difficult to
assess the extent to which Medicaid rates currently have slack or need
to be raised, although there seems to be general agreement and indirect
evidence that they are too low. Thus, it would be helpful for any
reimbursement increases to be tied to increased transparency about
financial flows. Second, the increased reimbursement should be tied
explicitly to spending on staffing.
A final note is that minimum staffing ratios are just that--
minimal--and will likely be binding only for the lowest-quality
facilities that currently have the most Medicaid residents and the
fewest staff. Prioritizing these facilities makes sense. Substantially
improving staffing across the entire industry would take more
fundamental and multi-faceted rethinking of the way in which we deliver
and pay for nursing home care.
Question. In your written testimony, you discussed your support for
the nursing home strike teams policy included in the American Rescue
Plan Act as a way to fill gaps that facilities may be experiencing
during the pandemic. You also indicated that you oppose the approach
taken under the Trump administration, whereby the Department of Health
and Human Services distributed $2 billion in incentive payments to
nursing homes from the Provider Relief Fund based on their relative
rates of COVID-19 cases and deaths.
What information should HHS and States take into consideration when
allocating these funds to ensure the facilities that need the most
support preventing and responding to COVID-19 outbreaks receive it, and
that racial disparities in nursing homes are taken into account?
Answer. Assistance during a crisis needs to be allocated based on
risk and need, not on some notion of merit. Strike teams and other
emergency assistance need to get to nursing homes on the verge of an
outbreak immediately. First, this requires HHS and states to ensure
that facilities have adequate testing supplies and are testing at least
as often as recommended by CDC guidance. A critical step is that once
one or more cases are identified, all residents and staff need to be
tested, and those who test positive need to be physically separated
from those who test negative. Low-resourced facilities may struggle to
implement these necessary steps with the required speed and may benefit
from strike teams for assistance. The roles of HHS and the state need
to include ongoing, regular communication with facilities about testing
supplies, turnaround time for results, and the identification of
positive cases, as well as the ability to send in strike teams
immediately. The key is speed and regular communication.
I don't believe it is necessary to specifically target nursing
homes with more residents of color. Rather, policy-makers should
prioritize areas and nursing homes at highest risk to make sure they
get the assistance they need. Nursing home residents of color have been
particularly hard hit during this pandemic because they are more likely
to be in large nursing homes in areas where COVID-19 rates are high. If
policy-makers focus assistance on areas and homes with the highest
COVID-19 risk, the assistance will go disproportionately to residents
of color, working to reduce the disparity.
Finally, I repeat from my testimony that addressing a crisis should
not be viewed in the same way as long-run efforts to improve the
quality of nursing home care. Addressing a crisis may entail providing
assistance to nursing homes that policy-makers view as ``undeserving''
due to underlying quality problems or for-profit status. The assistance
can be in-kind or come with strings to make sure it is used for the
intended purpose, but a crisis is not the time to implement an
incentive and reward system, or the residents may pay the price.
Question. A recent paper published by the National Bureau of
Economic Research found that people who receive treatment in nursing
homes owned by private equity firms have worse health outcomes than
those living in facilities under other ownership structurers. This
paper adds evidence to reports of worse outcomes associated with
private equity's investment in the nursing home industry. Nursing homes
have also become popular investments for real estate investment trusts
(REITs), which often lease back properties to private equity firms or
other related parties. The involvement of private equity in the nursing
home industry has been of interest to the Finance Committee for more
than a decade, and was a topic of interest for members during this
hearing. In your testimony, you noted the urgent need for greater
transparency regarding nursing home ownership structurers in light of
``the dominance of for-profit ownership, the growing role of private
equity, cross-subsidization from Medicare, and complex ownership
arrangements such as related-party transactions,'' making it
``difficult to see where taxpayer money is being spent, and what profit
margins truly are.'' Please answer the following.
If you have any other examples of issues associated with these
ownership arrangements, please provide them.
Answer. The paragraph above captures the essence of this problem. I
do not have additional examples, but would like to describe my broader
perspective on the role of private equity in the nursing home industry.
The main advantage to society of a private-equity takeover in any
sector is, in theory, the creation of efficiencies. The firm that is
bought might have untapped potential for cost-cutting or a more
profitable organizational structure, which private equity owners then
capitalize on. Investors get a return and the resulting firm is leaner.
In the nursing home sector, it is not clear that this is a desirable
goal, even if health outcomes did not suffer. Efficiencies may be
created, but they accrue neither to the taxpayer funding the care, nor
to the patient getting the care. So, what great advantage does this
increased efficiency bring? In a sector where the main challenge has
been quality, for a population that often cannot advocate for itself, I
don't see any advantage of private equity buyouts--with many potential
downsides.
Question. You noted the need for greater transparency in your
testimony. Please provide specific recommendations about the types of
transparency measures you suggest the Congress consider.
Answer. First, requirements to clearly report all owners involved
in related party transactions need to be enforced. Second, I would
recommend improving financial transparency by (1) reinstating the
requirement that nursing homes receiving Federal funding file annual
Medicare cost reports; (2) requiring similar financial reporting across
all related parties, such that profits and losses for the entire entity
can be assessed; and (3) requiring similar financial reporting for
chains as a whole. This type of reporting is a first step in
calculating two critical data points for related policies--the percent
of Medicare and Medicaid dollars spent on patient care, and the
adequacy or inadequacy of Medicaid reimbursement rates.
Transparency is not the end goal, but a necessary step to inform
appropriate policy. At the same time, requiring transparency may reduce
some of the incentive to engage in complex ownership arrangements.
Question. Are you aware of any evidence or data that show residents
or staff of facilities owned by private equity firms have fared worse
or experienced worse outcomes during the COVID-19 pandemic?
Answer. There have been two studies that I know of that directly
examined this question (Braun et al., 2020; Gandhi et al., 2020).
Somewhat surprisingly to many, neither of the studies found that
nursing homes owned by private equity firms had worse COVID-19
outcomes; in fact, results of the more rigorous study suggested that
private-equity-owned nursing homes had better outcomes (Gandhi et al.,
2020).
These findings are consistent with the rest of the evidence on
COVID-19 outcomes which found that the underlying quality of the
nursing home had little influence. One possible interpretation for the
lack of an association is that the attributes of a nursing home
required for providing high-quality care in normal times are not
exactly the same attributes required for responding to a crisis.
Anecdotally, especially early in the pandemic, containing an outbreak
had more to do with procurement connections (to obtain testing and PPE)
than with quality. It is possible that private-equity owners did not
see large numbers of COVID-19 deaths being in the interest of
profitability and that they possibly even assisted with procurement.
Indeed, the article by Gandhi and colleagues found that private-equity-
owned nursing homes were less likely to have experienced shortages in
PPE. Of note, outcomes were more negative for nursing homes that had
been owned by private equity in the past, suggesting that once private-
equity owners sell a nursing home, any resource-related advantages
disappear.
Question. Section 6101 of the ACA sought to increase transparency
of nursing home ownership structures. To date, CMS has not fully
implemented or enforced this section of the ACA, although the agency
does have existing reporting mechanisms for nursing home ownership that
provide a certain amount of information to the public. As the committee
considers the impacts of the changing ownership landscape in the
nursing home industry, would implementing section 6101 provide
sufficient transparency? Are there additional measures the committee
should consider?
Answer. Implementing and fully enforcing section 6101 would be
helpful in identifying the parties involved in these complex ownership
arrangements, which seems necessary but not sufficient. It is not clear
to me that section 6101 would enable a financial analysis of where the
money flows once these parties are identified. This broader financial
analysis is critical to assessing the two issues I noted above: the
percent of Medicare and Medicaid dollars spent on patient care, and the
adequacy or inadequacy of Medicaid reimbursement rates. Estimates of
these are essential for any policies aimed at improving the quality of
nursing home care.
______
Questions Submitted by Hon. Elizabeth Warren
Question. Private equity facilities own approximately 11 percent of
nursing homes nationwide.\2\ For years, reports have highlighted that
private equity owned facilities provide worse care than other nursing
homes. According to one 2014 study, private equity-owned facilities
generally ``deliver poorer quality of care'' than other chain-
affiliated for-profit facilities; are likely to try to reduce cost by
``substituting expensive but skilled RNs with cheaper and less skilled
nurses''; and ``report significantly higher number of deficiencies''
that climb with more years of private equity ownership.\3\ A study
released last month similarly showed found that private equity
ownership of nursing homes ``increases the short-term mortality of
Medicare patients by 10 percent, implying 20,150 lives lost due to
[private equity] ownership over [a] 12-year sample period.''\4\ Private
equity ownership was also associated with ``declines in other measures
of patient well-being, such as lower mobility'' and taxpayer
spending-per-episode increases of 11 percent.\5\ Meanwhile, an
Americans for Financial Reform analysis of long-term care facilities in
New Jersey found higher rates of COVID-19 infection and death at PE-run
sites.\6\ However, it is challenging to identify specific ownership
structures of nursing homes based on existing CMS data.\7\
---------------------------------------------------------------------------
\2\ Skilled Nursing News, ``COVID-19 Brings Private Equity
Investment in Nursing Homes Into the Spotlight,'' Alex Spanko, March
19, 2020, https://skillednursingnews.com/2020/03/covid-19-brings-
private-equity-investment-in- nursing-homes-into-the-spotlight/.
\3\ Journal of Health Care Finance, ``Private equity ownership of
nursing homes: Implications for quality, June-July 2014'' Rohit Pradhan
et al., October 2015, http://healthfinancejournal.
com/index.php/johcf/article/view/12.
\4\ National Bureau of Economic Research, ``Does Private Equity
Investment in Healthcare Benefit Patients? Evidence From Nursing
Homes,'' Atul Gupta, Sabria T. Howell, Constantine Yannelis, and
Abhinav Gupta, February 2021, https://www.nber.org/system/files/
working_papers/w28474/w28474.pdf.
\5\ Id.
\6\ Americans for Financial Reform, ``Report: The Deadly
Combination of Private Equity and Nursing Homes During a Pandemic,''
August 6, 2020, https://ourfinancialsecurity.org/2020/08/report-3-
private-equity-nursing-homes-coronavirus/.
\7\ Health Affairs, ``These Administrative Actions Would Improve
Nursing Home Ownership and Financial Transparency in the Post COVID-19
Period,'' Charlene Harrington et al., February 11, 2021, https://
www.healthaffairs.org/do/10.1377/hblog20210208.597573/full/.
In studying the quality of care provided at American nursing homes,
what challenges, if any, exist in identifying facility owners? How do
those challenges affect researchers' ability to assess quality of care
differences between for-profit and non-profit nursing homes, including
---------------------------------------------------------------------------
homes owned by private equity firms?
Answer. Enormous challenges remain in identifying nursing facility
owners. Some progress has been made following provisions in the
Affordable Care Act requiring nursing homes to reveal ownership
structures, but these data are incomplete and unaudited. Depending on
the research question, this is sometimes an impediment to conducting
research on nursing home quality; it is not an impediment to
comparisons of for-profit to nonprofit nursing homes but is an
impediment when comparing chain-owned facilities by chain or with
independent facilities. More importantly, it is a major impediment to
assessing the flow of taxpayer money, the percent being spent on
patient care, and the adequacy of payment rates.
Question. What additional information, if any, could the Centers
for Medicare and Medicaid Services collect on nursing home ownership
that could aid regulators or researchers studying quality of care
issues, or families seeking high quality nursing homes?
Answer. It would be helpful to regulators and researchers to have
more complete and audited data on ownership structures and cost reports
that allow an assessment of the flow of taxpayer dollars, the percent
that is being spent on patient care, and profit margins that take into
account all related parties. It seems to me that not having these
assessments presents a serious obstacle to meaningful policy change
aimed at increasing the quality of nursing home care. If we don't know
what the money is being used for, how can we tell if it is adequate or
how much additional reimbursement is needed to produce the desired
level of quality?
It is less clear how families seeking high-quality nursing homes
would use the ownership information, assuming they do not have strong
prior beliefs about which ownership structures are associated with
higher quality. We know that consumers sometimes view nonprofit status
as a signal for quality, and that information is already available. As
the research on these more complex ownership structures becomes
clearer, the information could become more useful.
Question. What improvements, if any, could the Centers for Medicare
and Medicaid Services make in the presentation and public availability
of nursing home ownership data--for example, in terms of formatting,
update frequency, etc.--to help regulators or researchers studying
quality of care issues, or families seeking high-quality nursing homes?
Answer. For decades, it has been arduous or impossible to identify
which nursing homes belong to which chains; the chain indicator
available in CMS data reflects joint ownership of two or more
facilities, not a very useful demarcation, and the chain name field is
so inconsistent as to be useless. This makes rigorous research on
chains difficult, and presents a barrier to the assessment of overall
quality for particular chains. CMS could solve this issue by posting
chain status and a consistently worded chain name on Care Compare, with
updates as they occur.
Question. What, if anything, has the COVID-19 pandemic revealed
about the role of private equity in the U.S. nursing home industry and
the safety of residents in private-equity-owned facilities?
Answer. There have been two studies that I know of that directly
examined this question (Braun et al., 2020; Gandhi et al., 2020).
Somewhat surprisingly to many, neither of the studies found that
nursing homes owned by private equity firms had worse COVID-19
outcomes; in fact, results of the more rigorous study suggested that
private-equity-owned nursing homes had better outcomes (Gandhi et al.,
2020).
These findings are consistent with the rest of the evidence on
COVID-19 outcomes, which found that the underlying quality of the
nursing home had little influence. One possible interpretation for the
lack of an association is that the attributes of a nursing home
required for providing high-quality care in normal times are not
exactly the same attributes required for responding to a crisis.
Anecdotally, especially early in the pandemic, containing an outbreak
had more to do with procurement connections (to obtain testing and PPE)
than with quality. It is possible that private-equity owners did not
see large numbers of COVID-19 deaths being in the interest of
profitability and that they possibly even assisted with procurement.
Indeed, the article by Gandhi and colleagues found that private-equity-
owned nursing homes were less likely to have experienced shortages in
PPE. Of note, outcomes were more negative for nursing homes that had
been owned by private equity in the past, suggesting that once private-
equity owners sell a nursing home, any
resource-related advantages disappear.
Question. What steps do you believe the U.S. Congress should take
to minimize risks to patients living in private-equity-owned nursing
facilities, including but not limited to risks related to staffing,
infection control, and future pandemics?
Answer. I do not believe that private equity should have a role in
owning nursing homes, so some steps on the part of the U.S. Congress
are warranted. There are several ways to reduce the growth in private-
equity ownership. One is to simply ban these leveraged buyouts; given
the extent of public funding for nursing home care, this could be
justified. Another is to make the nursing home sector much less
attractive to private equity. This might be achieved through policies
that simultaneously work to improve the quality of care and would serve
to protect those already living in facilities owned by private equity:
requiring minimum staffing ratios and requiring that a certain
percentage of revenues be spent on patient care.
______
Questions Submitted by Hon. John Barrasso
Question. An article in the March edition of Health Affairs points
out that although staff turnover is an important indicator of nursing
home quality, this has never been included on the Nursing Home Compare
website, maintained by Medicare.
Please discuss the impact of staffing turnover on the quality of
care provided in nursing homes.
Answer. A fairly large body of evidence suggests that nursing homes
with higher staff turnover have lower quality of care. The research is
of mixed quality, with two main challenges. First, national data on
turnover have not been available until very recently with the
implementation of the payroll-based journal system, the data used in
the Health Affairs article. Thus, most studies of turnover are small
and localized. Second, while high turnover is associated with poor
quality, the causal connections are unclear. Does high turnover lead to
poor outcomes, or do nursing homes with low quality just have more
trouble retaining staff? In any case, there is face validity to a
causal relationship: If staff members do not stay long enough to get to
know residents and their needs, problems and changes may go unnoticed
and communication may be lost in the frequent transitions.
Question. Specifically, do you believe turnover rates from nursing
homes should be made more readily available for public review?
Answer. I would not prioritize it, though it could do some good.
Public reporting has two main goals: to provide information to
consumers and to incent improvement by providers. For consumers, the
question I would ask is: Would posting turnover rates tell them
anything new? As established in the Health Affairs article, turnover
rates are highly correlated with the overall star ratings in the
direction one would expect. Thus, adding turnover rates to the system
would be unlikely to change consumers' choices, though perhaps some
consumers would be particularly interested in this measure. I would be
much more enthusiastic about adding patient experience measures, which
are central to how we think about quality in long-term care but are
completely missing from Care Compare.
Even if not very useful to consumers, publicly reporting turnover
rates could lead providers to pay more attention to turnover and to try
to reduce it. For this reason, there may be some benefit to public
reporting of turnover rates. I still believe the need for it is
outweighed by the compelling need to add patient experience measures.
______
Questions Submitted by Hon. Todd Young
Question. As outlined in many of your testimonies, the visiting
restrictions and isolation necessitated by the COVID-19 pandemic took a
heavy toll on the emotional and mental health of many nursing home
residents separated from their family members and other loved ones.
Fortunately, with increased vaccination and declining COVID-19 deaths,
many of these restrictions have been lifted.
While we hope that restrictions of this scale will not be necessary
again, it is worth examining ways to alleviate the negative emotional
and mental health effects that isolation may have on nursing home
residents. The use of technology, for one, has allowed residents to
interact virtually with family and other loved ones from whom they are
otherwise separated. Expanded use of telehealth has also helped
residents access routine health-care services while limiting spread of
the coronavirus.
What are some lessons learned from the public health emergency in
terms of the integration of technology in nursing homes--both in
helping residents visit virtually with loved ones and in accessing
health-care services?
Answer. The expanded use of technology has been one of the silver
linings of this pandemic across health-care sectors, even though it
cannot fully substitute for in-person interaction and contact. This has
been true in nursing homes as well, with some caveats. One caveat is
that many older adults, especially those with dementia, are
uncomfortable with these technologies. Another caveat, related to the
first, is that using them requires time and effort of nursing home
staff to facilitate. Nursing homes have exhibited understaffing for
decades and this was exacerbated during the pandemic, so facilitating
video visits became another task on the list competing for staff time.
Nonetheless, while I am not aware of large-scale studies examining the
effects of video visits in nursing homes, it seems safe to say that
they mitigated the effects of social isolation to some extent and
allowed family members some ability to monitor the mental and physical
well-being of the resident.
Question. How do you anticipate this type of technology continuing
to be used beyond the pandemic?
Answer. I expect that the use of technology to facilitate video
visits with family and health-care providers will become standard. Even
without the need for social isolation, there are numerous situations in
which an in-person visit is not possible or not advised, for example
when a family member lives far away or is ill. Increased use of
televisits may also reduce the need for some transfers of residents for
routine health care. It could also enable more frequent monitoring and
may be a cost-
effective way to enable some to remain at home, and out of the nursing
home, a little longer.
______
Question Submitted by Hon. John Cornyn
Question. Your testimony notes the lack of vaccine uptake by
nursing home staff. This coupled with high turnover can lead to higher
risks for residents.
What recommendations do you have to address the issue of vaccine
reluctance and improving staff retention?
Answer. Vaccine hesitancy among nursing home staff is a significant
problem. To the extent that some of the hesitancy is due to the
vaccines being new and people wanting to gather evidence about how
others have fared, rates should increase as time passes. There are also
several things that policy-makers and nursing home managers can
actively do: (1) continue to provide education and public health
messaging about the safety and efficacy of the vaccines and the dangers
of COVID-19; and (2) make the logistics of getting the vaccine easy,
e.g., through repeated on-site vaccine clinics for staff and new
residents. If staff who originally declined now have to find their own
appointments for vaccines off-site, it will be a significant obstacle
to increasing take-up. Other small nudges may also help, such as
requiring unvaccinated staff to wear more protective equipment. While
the vaccines are still under Emergency Use Authorizations, any more
significant nudges (such as bonuses) or mandates seem ethically
questionable.
Improving staff retention is a bigger problem that will require
fundamental policy reforms. It is difficult to imagine making anything
but small, incremental progress unless we change the way we treat
nursing home and home health caregivers. As long as they make minimum
wage and often have no sick pay or benefits or promotion prospects
while doing physically and mentally demanding work, there will be
understaffing and there will be turnover; understaffing and turnover
tend to move together. Increasing Medicaid reimbursement and tying it
to increased staffing would be a start.
______
Questions Submitted by Hon. James Lankford
Question. During the hearing, you mentioned the benefits of States
having essential caregiver programs.
What are other ways States and localities can encourage increased
family engagement and oversight in order to ensure the proper safety of
a facility for their loved one? In what ways can Federal entities like
CMS ensure participants in family engagement programs, such as
essential caregivers, are given the utmost access to information
regarding their loved one?
Answer. Family engagement and oversight are critical to the well-
being of nursing home residents, not just for safety but for quality of
life. Although they are not always mutually exclusive, I believe that
safety and clinical outcomes are too often prioritized over quality of
life, in part because safety and clinical outcomes are what we measure
and reward. During the pandemic, I believe that CMS should have
encouraged (or even mandated) all States to adopt essential caregiver
programs, while providing the testing and PPE resources to do so
safely. Any increased COVID-19 risk (likely small) would have been
outweighed by the benefits of these interactions.
I see two main impediments to full communication and resident
engagement with family members, both of which exist in more normal
times but were exacerbated by the pandemic. The first concerns fears of
regulatory action or litigation if negative information is disclosed. A
fear-based system is never conducive to openness; there should be some
reward to being fully transparent and open, perhaps in the form of
reduced risk of regulatory sanctions or litigation.The second main
impediment is resources. Although families often help with care, full
communication with families and the facilitation of family engagement
requires time and effort on the part of nursing home managers and
staff. We have a system of nursing home care in which, for many
facilities, there seems to be a crisis every day. During the pandemic,
this was the case for most facilities. When staffing is so short that
basic care needs are being neglected, communication with families is
unlikely to be prioritized. Solving this issue will require significant
reforms, likely involving increased Medicaid reimbursement tied to
higher staffing standards.
One additional way to improve openness and communication with
families is to publicly report resident and family satisfaction with
the level of communication. In a review of the evidence on Nursing Home
Compare that I recently published (Konetzka et al., 2020), we
identified resident and family experience and satisfaction as a
critical gap in what we report, and communication would be an element
of that addition. We know that providers tend to focus on what is
measured and what is reported, so this could help, at least
incrementally.
References
Braun, R.T., Yun, H., Casalino, L P., Myslinski, Z., Kuwonza, F.M.,
Jung, H.Y., and Unruh, M.A. (October 1, 2020). Comparative
Performance of Private Equity-Owned US Nursing Homes During the
COVID-19 Pandemic. JAMA Network Open, 3(10), e2026702. https://
doi.org/10.1001/jamanetworkopen.2020.26702.
Davila, H., Shippee, T.P., Park, Y.S., Brauner, D., Werner, R.M., and
Konetzka, R.T. (September 28, 2020). Inside the Black Box of
Improving on Nursing Home Quality Measures. Med Care Res Rev,
1077558720960326. https://doi.org/10.1177/1077558720960326.
Gandhi, A., Song, Y., and Upadrashta, P. (August 28, 2020). Have
Private Equity Owned Nursing Homes Fared Worse Under COVID-19?
(August 28, 2020). Available at SSRN: https://ssrn.com/
abstract=3682892 or http://dx.doi.org/10.2139/ssrn.3682892.
SSRN preprint. http://dx.doi.org/10.2139/ssrn.3682892.
Konetzka, R.T., and Werner, R.M. (October 2009). Disparities in long-
term care: Building equity into market-based reforms. Med Care
Res Rev, 66(5), 491-521. https://doi.org/1077558709331813 [pii]
10.1177/1077558709331813.
Konetzka, R.T., Yan, K., and Werner, R.M. (2020). Two Decades of
Nursing Home Compare: What Have We Learned? Medical Care
Research and Review [published online ahead of print, June 13,
2020].
Mor, V., Zinn, J., Angelelli, J., Teno, J.M., and Miller, S.C. (2004).
Driven to tiers: Socioeconomic and racial disparities in the
quality of nursing home care. Milbank Q, 82(2), 227-256.
Perraillon, M.C., Brauner, D.J., and Konetzka, R.T. (August 1, 2017).
Nursing Home Response to Nursing Home Compare: The Provider
Perspective. Med Care Res Rev, 1077558717725165. https://
doi.org/10.1177/1077558717725165.
______
Prepared Statement of Quiteka Moten, MPH, CDP, State Long-Term Care
Ombudsman, Commission on Aging and Disability, State of Tennessee
biography
Quiteka ``Teka'' Moten works for the Tennessee Commission on Aging
and Disability as the State Long-Term Care Ombudsman. Teka is from
Memphis, TN and is a graduate of the University of Tennessee--Knoxville
with a B.A. in interdisciplinary studies and a B.A. in sociology.
Following undergrad, Teka worked as senior programs coordinator for the
YWCA in Knoxville. Next, she managed programs and policy efforts for
the Alzheimer's Association in South Central Tennessee. During this
time, she worked to establish rural senior networks, train first
responders, and manage early-stage engagement programs and respite
grants.
Following her time with the Alzheimer's Association, Teka pursued
her master of public health in behavioral sciences at Tennessee State
University while working as a government contractor. Passionate about
supporting caregivers, Teka has spent years assisting families affected
by Alzheimer's and other dementias. Through providing hands-on
training, care plan management, and respite referrals, Teka makes use
of her Certified Dementia Practitioner and PAC Dementia Coach
designations by training caregivers and health-care professionals. She
has made appearances on several local television and radio programs
throughout the State and southern region--most notably are her features
in NPT's ``Aging Matters'' series.
overview of the ombudsman program (omb)
The Long-Term Care Ombudsman Program (LTCOP) is an essential
component to the oversight of communities such as skilled nursing
facilities, assisted care living facilities, and residential homes for
the aged, or (SNFs, ACLFs, and RHAs). There are 1,362 staff Ombudsmen
(FTE) including 50 States along with DC and Puerto Rico and 5,947
designated volunteer Ombudsmen in the Nation. For context's sake, there
are 16,253 nursing facilities per NORS 2019, Total Counts.\1\
---------------------------------------------------------------------------
\1\ See Aging, Independence, and Disability (AGID) Program Data
Portal: https://agid.acl.gov/DataGlance/NORS/.
The structure of each State Long-Term Care Ombudsman Program varies
based upon organizational criteria developed by NASUAD (National
Association of States United for Aging and Disabilities).\2\ Major
activities of the Tennessee Long-Term Care Ombudsman Program include
required visits, reporting, mandatory meetings with other State
agencies, follow-up on facility-initiated discharges, and coordination
of the volunteer Ombudsman programs (VORs).
---------------------------------------------------------------------------
\2\ State Long-Term Care Ombudsman Programs: Organizational
Structure: https://ltcombudsman.org/uploads/files/support/NASUAD-2016-
Ombudsman-Rpt.pdf.
The cases for the LTCOP are resolved through complaint
investigations as laid out in the CMS State Operations Manual. LTCOP
representatives investigate individual complaints and address concerns
that impact residents in facilities. Long-Term Care Ombudsmen (LTCOs)
can also address general concerns they personally observe during a
visit (e.g., odors, concerns about the environment, staff not knocking
on resident doors before entering rooms.) As LTCOPs are resident-
directed, LTCOs cannot share information without resident consent.
Investigations by LTCOP representatives are done to gather facts, but
---------------------------------------------------------------------------
the main goal is to resolve the issue to the residents' satisfaction.
The LTCOP operates as a community-based, bedside advocacy program
working to uphold residents' rights. The Nursing Home Reform Act
established the following Residents' Bill of Rights:\3\
---------------------------------------------------------------------------
\3\ The 1987 Nursing Home Reform Act: https://www.aarp.org/home-
garden/livable-communities/info-2001/
the_1987_nursing_home_reform_act.html.
The right to live in a caring environment free from abuse,
mistreatment, and neglect.
The right to live without the fear of enduring physical
restraint.
The right to privacy.
The right to receive personal care that accommodates physical,
medical, emotional, and social needs.
The right to a social contact/interaction with fellow residents
and family members.
The right to be treated with dignity.
The right to exercise self-determination.
The right to exercise freedom of speech and communicate freely.
The right to participate in the creation and review of one's
individualized care plan.
The right to be fully informed in advance of any changes to care
plan or status of the nursing home.
The right to voice grievances without discrimination or
reprisal.
how covid impacted the omb program
COVID and the ensuing policies disrupted the Ombudsman Program's
immediate access to residents (as provided for in the Code of Federal
Regulations). The inability to have face-to-face meetings made it
difficult to verify complaints, assure confidentiality and readily gain
consent from residents and/or their medical surrogates. It also made it
difficult to advocate for residents dealing with facility-initiated
discharges (oftentimes leaving them in behavioral health or medical
centers with the risk of losing Medicaid). Particularly affected by
these issues were people living with dementia (PLWD); those who were
aphasic or unable to speak; those who were deaf, hard of hearing or,
have assistive technology needs; those without the manual dexterity to
use a phone; and those without funds to purchase their own.
In addition, the workforce shortage in nursing homes was further
exacerbated by COVID. Lack of staffing and an inability to be with
their family had a major impact on residents. Some of the complaints
received by the Tennessee Long-Term Care Ombudsman Program included:
An overall decline in quality of care in many facilities;
Unanswered call lights, not getting basic care/assistance, and
dehydration;
Issues with repositioning which left residents in bed resulting
in an exponential increase in bed sores;
Unchanged catheters and pressure sores resulting in sepsis and
death;
Issues of dignity and hygiene stemming from residents having to
sit in their own urine and feces for hours;
Delayed discharges to hospitals for treatment of serious
conditions, facility-
initiated hospice;
Communication issues with facilities and privacy concerns by
families;
Resident isolation (resulting in emotional distress and leading
to physical decline); and
COVID infection cases, issues surrounding cohorting residents,
and room changes.
solutions
There are a few contemplations as the Tennessee State Long-Term
Care Ombudsman:
1. There is a need to reform the strategy of recruiting and
retaining staff support especially with a rapidly growing elderly
population.
2. It's fair to make the argument that LTCOP's are an essential
piece of the system that seeks to respond to and support the health,
safety, and welfare of residents regardless of any status a State may
have bestowed upon the program.
3. There is a need for more Geri-psych units. Residents are
typically held for 2 weeks if sent out by nursing homes; that is
usually not enough time for the medications residents received to cycle
out of their systems and then hold the resident for observation.
4. There should be an established, uniform system for
communicating with families in the event of a PHE or natural disaster.
______
Questions Submitted for the Record to Quiteka Moten, MPH, CDP
Questions Submitted by Hon. Ron Wyden
Question. The Centers for Medicare and Medicaid Services (CMS)
issued an interim final rule last year that required nursing homes to
report COVID-19 data to the Centers for Disease Control and Prevention
on a weekly basis beginning May 17, 2020. These data included COVID-19
infections, COVID-19 deaths, and the availability of key equipment and
workers at individual nursing homes. The data have proved to be helpful
for the public, policy-makers, and industry stakeholders to track the
pandemic, and related issues, in these care settings. However, to date,
CMS has not required nursing homes to provide such data prior to May 8,
2020, despite calls from Senate Democrats to do so. In September 2020,
the Government Accountability Office (GAO) noted that ``by not
requiring nursing homes to submit data from the first 4 months of 2020,
HHS is limiting the usefulness of the data in helping to understand the
effects of COVID-19 in nursing homes.'' GAO went on to recommend that
``HHS, in consultation with CMS and CDC, develop a strategy to capture
more complete data on COVID-19 cases and deaths in nursing homes
retroactively back to January 1, 2020.''
Do you support GAO's recommendation? Why or why not? Please briefly
explain.
Answer. I agree with the recommendation by GAO to ``develop a
strategy to capture more complete data on COVID-19 cases and deaths in
nursing homes retroactively back to January 1, 2020.'' Unfortunately,
this is needed because the cases and deaths in nursing homes often
mirrored that of their counties/communities. By contrast, this was not
the case in many hospitals and Emergency Department (or ED) settings.
With that, exploration into the complete data would help better examine
the transmission of COVID earlier on in skilled nursing facilities and
other long-term care facilities. The standards for care in each State
spell out required documentation that may assist in accomplishing data
collection.
Question. During the hearing, several Senators and witnesses raised
the importance of the Federal Government collecting and publishing
information from individual nursing homes that show the rate of
vaccinations for residents and staff. Since that time, a bipartisan
group of senators have sent a letter to the U.S. Department of Health
and Human Services calling on it to take steps to begin this data
collection.
Do you support this type of information being made public? How
would it help the work of Long-Term Care Ombudsmen and their role
protecting the rights of residents in nursing homes and other
congregate living facilities?
Answer. Information on residents' vaccination percentages should
and have been made public through Federal Pharmacy Partnerships and
respective QIOs. Allowing the publication of information on staff
vaccination percentages, however, is a bit more difficult to weigh in
on due to risk of exposing PHI (like HIPPA) and leaving staff
vulnerable to pressures by other staff and their community as a result.
Nonetheless, the Ombudsman Program and other pertinent State agencies
should be privy to this information--even if aggregated--so that we
have a better understanding of risks for residents and their families
as well as our own. This would also help to inform conversations around
re-entry practices and needs for targeting community education to
encourage vaccination(s) where possible. In addition, for Ombudsman
Programs and other stakeholders working on respective ad hoc State
COVID committees, this information would assist in continuing to form
expectations for visits as we hopefully move closer to herd immunity.
Question. In preparation for this hearing, Oregon's Ombudsman
provided my office with reports documenting issues that long-term care
residents in the State have faced over the last year. They read like a
list of nightmares. The Oregon Ombudsman received reports of residents
being left in soiled clothing for hours, patients that developed
pressure sores that reached bone, and falls that went unreported by
facilities. These types of problems aren't unique to Oregon. Yet, it's
clear the pandemic has reduced basic protections of the Nation's most
vulnerable.
How has the pandemic impacted your work looking out for the well-
being of nursing home residents, and how did the pandemic affect the
number and types of complaints your office received?
Answer. The pandemic impacted the mechanisms for consumer
protection and advocacy of residents by hindering immediate access.
Without the ability for families or the Ombudsman Program (and in some
instances first responders) to readily gain facility access, instances
of neglect, abuse, exploitation, and untreated medical conditions that
did not rise to the level of immediate jeopardy, or IJs, often times
went unreported. In addition, due to visitation restrictions, Ombudsmen
were unable to make quarterly visits to skilled nursing facilities
albeit a Federal requirement--and a source of many of the cases opened
by virtue of in-person observation. With that, nationally, the
Ombudsman Program saw a decrease in complaints throughout the first
wave of COVID. However, our offices were inundated with calls and
concerns for visitation and care questions that may not have risen to
the level of opening a case/complaint resulting in an exponential
increase in Information and Assistance calls to the Ombudsman Program.
Question. The Centers for Medicare and Medicaid Services issued new
visitation guidance on March 10, 2021, that will make it easier for
nursing home residents to receive visitors. Do you expect that the
administration's policy will make it easier for you to do your job
looking out for the safety of long-term care residents?
Answer. The new guidance visitation issued on March 10, 2021 was
merely 3 days short of having been in place for an entire year, so the
new guidance was obliging in many respects with a few reservations. The
visitation guidance was helpful in reestablishing expectations for
allowing residents their rights to visit (or guardrails if you will--
especially in States that were no longer following State specific
guidance). So, short answer--yes, it makes our job easier cause we
finally have good news to share. In addition, what resulted from the
guidance was hope for residents and families--but for facility staff
and State government, its immediacy placed a strain on areas that were
still experiencing high rates of positivity, COVID outbreaks, or staff
testing positive. Lastly, there was seemingly vague language that went
weeks without clarity until national webinars.
______
Question Submitted by Hon. John Barrasso
Question. A top concern of Wyoming nursing facilities is making
sure there are enough staff to care for residents.
Many Wyoming nursing homes provide professional development and
other educational opportunities to attract and maintain their staff.
Can you discuss solutions related to workforce development you
believe will improve the ability of nursing facilities to attract and
maintain direct care staff?
Answer. Perhaps the most polarizing issue for long-term care
facilities during COVID was the workforce shortage. The concern speaks
to a few issues--lack of childcare, education equity, corporate
responsibility, and general fiduciary oversight, but most importantly--
quality of care for residents. Providing care in a nursing home setting
is tough! It requires physical strength and often mental restraint; we
received a myriad of complaint calls from staff detailing just that.
solutions for workforce development include:
Temporary CNAs progression: Working through a process for
temporary CNAs based on education and time in facility during the
pandemic.
WIOA grants: Consideration for collaboration with WIOA
Eligible Training Programs to award additional funds to students
working towards non-credit certifications who are willing to do both
school and work in facilities.
Childcare provision: Developing childcare centers in wings of
facilities that are not at full census for staff who are single parents
and/or may not qualify for assistance.
Student Loan Forgiveness: Quite possibly the greatest way to
attract almost anyone who has amassed quite a bit of debt.
______
Questions Submitted by Hon. Todd Young
Question. As outlined in many of your testimonies, the visiting
restrictions and isolation necessitated by the COVID-19 pandemic took a
heavy toll on the emotional and mental health of many nursing home
residents separated from their family members and other loved ones.
Fortunately, with increased vaccination and declining COVID-19 deaths,
many of these restrictions have been lifted.
While we hope that restrictions of this scale will not be necessary
again, it is worth examining ways to alleviate the negative emotional
and mental health effects that isolation may have on nursing home
residents. The use of technology, for one, has allowed residents to
interact virtually with family and other loved ones from whom they are
otherwise separated. Expanded use of telehealth has also helped
residents access routine health-care services while limiting spread of
the coronavirus.
What are some lessons learned from the public health emergency in
terms of the integration of technology in nursing homes--both in
helping residents visit virtually with loved ones and in accessing
health-care services?
Answer. The major lesson of technology in nursing homes is that it
is only as good as (1) the staff's familiarity with the software/
hardware; and (2) their capacity to use it in a meaningful, person-
centered way. While there are success stories as it pertains to
telehealth and visitation, the reality is that many residents didn't
reap the benefits of technology due to the shortage of staff to meet
their care needs. For many in nursing homes, much of the care residents
required was outside a facility and could not be provided via
telehealth. And due to transmission-based protocols and fear of
quarantine, many residents went without medical care to avoid a 2-week
lockdown; in some instances, this included treatments like dialysis,
dental appointments/denture fittings, eye appointments, and other
medical circumstances that contribute to the quality of life for older
and vulnerable people.
Technology, while great as a concept and expenditure, is up to the
discretion of facilities. What we also learned about technology is that
there was:
An increase in use for end-of-life visits
(especially for long-distance caregivers).
An increase in use for cases in which APS, TBI, or
VAPITs were involved.
A contingency on its use depending on staffing
capacity at nursing homes. In facilities where community transmission
was mirrored, it meant that use of technology for communication took a
back seat to pushing paperwork and water carts.
There should be some consideration for standards on
virtual care plans and facility-initiated medical transfers to keep
families involved in the process and able to lay eyes on their loved
ones amidst tough decisions being made if ever visitation restrictions
are put back in place.
Question. How do you anticipate this type of technology continuing
to be used beyond the pandemic?
Answer. Beyond the pandemic--as more baby boomers age into Medicare
and the long-term care setting daily, I think there will be an uptick
in technology use. For many of those working in the almost $80-billion
elder care industry, it means the realization of a paradigm shift to
accompany the next generation. This mean not only reconsidering the
institution of skilled nursing facilities by design and activity
offering, it means:
Using technology for person-centered care of residents while
protecting their Personal Health Information, or PHI. If I had a magic
wand, there would be a means to personalize the experience of each
resident based on their intake info and schedule including pre-loaded
songs and movies that they genuinely enjoyed throughout childhood
through to present day.
Taking the opportunity to engage children and younger adults
on an intergenerational level; they could assist with programming
tablets and/or teaching residents how to work the equipment.
Retrofitting facilities to accommodate the needs and wants of
a generation who has a better grip on technology and a desire to have
it daily; there are several Life and Safety considerations forthcoming
for State departments of health.
Welcoming a more vocal generation into facilities that is
aware of technology and its many uses. This means conversations and
State bill introductions about technological equipment like smart
speakers, gadgets like smart displays for video chatting, and features
like AI-infused smart camera and smart sound.
Question. You mentioned the need for a uniform system for
communicating with families in the event of a public health emergency
or natural disaster. Could you elaborate on this recommendation?
Answer. In May 2020, the first of many requirements to notify
families of COVID was released by CMS. At that time, the guardrails
issued to inform families were broad to say the least. A skilled
nursing facility could select a myriad of ways to inform loved ones
including phone calls, automated calling services, text services, and
notices on facility/corporate home pages. Because novel coronavirus was
just beginning to take its toll, there was not yet a system in place to
deal with thoroughly explaining visitation restrictions/outbreaks, lack
of immediate access, and an inability for families to present when
needed to (1) interpret changed behavior, mood, or effect of loved
ones; and (2) have face-to-face discussions on care plans--and ensure
follow-through in person. This along with the workforce shortage led to
many facility phones going unanswered due to amount of staff, repeat
calls, calls from multiple family members of the same resident, request
from media, etc.
As we inch closer to herd immunity, the reality is that we should
use this time to devise a system by which families can readily
communicate with loved ones in facilities during public health
emergencies. Priority should be given to a system by which families are
notified when there is a facility-initiated hospital or Geri-psych
transfer along with facility-initiated hospice--none of these should
come as a surprise to families or happen without their consent
haphazardly unless it is a medical or behavioral emergency. This
ideally would be executed through a text messaging alert system
coordinated by Skilled Nursing Facilities, local health departments,
QIOs, the Ombudsman Program, and State departments of health.
______
Prepared Statement of Adelina Ramos, Certified Nursing Assistant,
SEIU District 1199 New England, Greenville, RI
Thank you to Chairman Wyden, Ranking Member Crapo, and members of
the Senate Finance Committee for inviting me to speak today. My name is
Adelina Ramos, and I'm a CNA at a nursing home in Greenville, RI. I am
a proud immigrant to this country, having moved here from Cape Verde
Islands off the western coast of Africa when I was child.
At my facility, I work with Alzheimer's patients. To be trusted by
families in my community to care for their loved ones is a great
privilege and honor. But over the past year, my days have been filled
with fear and sadness.
I don't think anyone in my small Rhode Island community thought
COVID-19 would arrive at our doorstep. But it did, and nursing homes
were not prepared. When COVID first hit, we lost over 20-plus residents
in just over a month. A CNA at my facility died too, and she was one of
the first nursing home workers to die of COVID in Rhode Island.
As more and more people in my facility tested positive, we
confronted management to let them know we didn't have the right PPE--
and what we had wasn't enough to last--or training to keep our
residents safe and prevent the virus from spreading in our facility.
We were extremely short-staffed too. At one point I was caring for
26 critically ill residents with only the help of one other CNA, a
nurse and a housekeeper. My residents couldn't eat or drink without
help. They couldn't move or get out of bed by themselves. They all
required oxygen changes every 15 minutes. And because they had
Alzheimer's, sometimes they would get very scared or angry.
It was horrifying. But management didn't seem to be too concerned
when my co- workers and I told them what was going on. We pleaded for
more staff on each shift, but they said they couldn't find anyone. And
so our residents and staff kept getting sick. They kept dying.
On Mother's Day, I realized I couldn't smell my ginger tea. I
thought it was because of my mask. I knew that was one of the symptoms
of COVID, but I wasn't experiencing anything else. When the National
Guard arrived to test people a few weeks later, I got the news I had
been dreading for so long: I was COVID-positive. I was asymptomatic,
and so I was unknowingly putting those around me at risk--at work and
at home.
My in-laws live with us, and I serve as their caregiver. They are
both in their late sixties and have preexisting conditions that put
them at high risk of contracting a serious case of COVID-19. I was
worried about infecting my husband, because then he wouldn't be able to
see his parents.
As a mother, I never thought I'd have to tell my 15-year-old son to
stay away from me. Don't touch me. Don't hug me. Don't get too close. I
knew I would never be able to forgive myself if I passed this deadly
virus on to my child. So I did what I had to do to keep him safe, even
though it broke my heart into a million little pieces.
Today, I'm COVID-free and vaccinated, and I can finally hold my son
close and care for my in-laws again. Things are looking up, but the
physical and emotional trauma this pandemic caused can't be cured with
a shot in the arm.
When I started working at a nursing home, I understood I'd have
residents pass away. But when that happens, our job is to make sure
they're comfortable, cared for and surrounded by loved ones in their
final moments. But because of the pandemic, family members couldn't
come into our facility to be with their dying parents, grandparents,
siblings, or friends. Normally, when someone passes away, the funeral
home comes to our facility to handle the body. But it wasn't safe for
funeral homes to enter our facility because they didn't have enough
PPE. So we became the morticians and had to put bodies into body bags.
Despite my years of training and the love I have for my residents,
there was nothing I could do to help them. Our residents felt so alone.
Because we were dressed head to toe in protective gear, they couldn't
tell who we were. They deserved so much better than what we were able
to provide with so few staff and resources. As they took their final,
difficult breath, I hope they knew that we tried our best. I hope they
knew that we loved them like family. I hope they knew that we didn't
mean to fail them.
Between April and June of last year, nursing homes in Rhode Island
received over $50 million dollars in State and Federal funding in
response to the COVID-19 crisis. That was on top of a Federal stimulus
payment of $2,500 per nursing home bed plus $50,000 per facility--
almost $26 million.\1\ Still, Rhode Island has one of the worst records
in the Nation for COVID-19-related nursing home deaths--six in 10
COVID-19 deaths were in long-term care settings.\2\ Where did all that
money go? How was this allowed to happen?
---------------------------------------------------------------------------
\1\ Crossroads of Care: Repairing Rhode Island's Nursing Homes in
the Wake of COVID-19, https://drive.google.com/file/d/
1uc3xZ9MxAIubUDTI4fRa8Fkp3D7NzA9c/view.
\2\ https://www.kff.org/coronavirus-covid-19/issue-brief/state-
covid-19-data-and-policy-
actions/.
But the pandemic didn't cause the issues we've faced--it only made
them worse. Rhode island currently ranks 41st in the country for the
average number of hours nursing home residents receive. The starting
wage for Rhode Island nursing home workers like me is just $12.34.\3\ I
am fortunate that I am a member of a union. My co-workers and I were
able to work together through our union to negotiate higher wages and
pandemic pay. I felt like I at least had an ability to advocate for
myself and my residents and shine a light on all the wrongs in our care
system, which COVID-19 exposed in the most tragic and deadly way. It
didn't have to be like this.
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\3\ https://dlt.ri.gov/documents/pdf/lmi/oesnrcf.pdf.
If you ask any CNA what their top issues are on the job, it's low
wages, unsafe staffing, and poor job quality. They are linked together.
I feel a calling to do this work and care for others. But it is hard to
do this job when you can't pay your bills, put dinner on the table or
afford to take your child to the doctor. Some of us have to work two or
three jobs, just to meet our basic needs. And all this is made harder
by the fact that because of short staffing, we don't have the time to
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spend with residents when they need us.
One of my hardest days during COVID-19 was when one of my patients
was slipping away and wanted me to sit at her bedside but I couldn't
stay because there were twenty other residents who also needed me. This
is the cycle we need to break.
Most nursing home workers are women and many of us are women of
color and immigrants--just like me. Centuries of systemic racism and
sexism have kept alive the false idea that care workers are unskilled,
uneducated, and just there to clean up. We've been denied a living wage
and crucial benefits like affordable health insurance and paid time
off, and too many of us don't have a union to advocate for ourselves
and our residents.
I am doing my part with my union and my coworkers. I was scared to
get the vaccine--many of us are, we have felt so disposable for so long
that there is a lack of trust--we didn't want to be test subjects. But
I did my research, I knew how important it was and how it would keep
me, my family, and my residents safe. And now I educate others about my
experience with the vaccine. It is why the union matters and the worker
voices matter--people in all communities need sources of information
that feel like they have their best interest at heart.
Our country's COVID death toll is nearing 600,000. That's more than
the populations of Baltimore, Atlanta, Miami and nearly three times the
population of Rhode Island's capital city, Providence.
Though vaccination rates are going up, giving us all hope that
soon, the infection rates will slow and the deaths will stop, the
population of Americans in need of long term care is skyrocketing. This
pandemic has shown us what happens when we're not prepared to meet the
demands for care.
Every shift must be appropriately staffed so residents--our
Nation's parents, grandparents and loved ones with disabilities--can
live with dignity and get the care they deserve and depend on. We still
need PPE. We need paid time off and affordable health care. We need
livable wages that allow us to provide for our families. And every
nursing home worker must have a seat at the table to be able to
negotiate a better life.
We refuse to be trapped in cycles of poverty and struggle to care
for our own families. We refuse to continue on with the deadly status
quo in this industry any longer. Change needs to happen now, and not
just on the State level. It's why we must raise the minimum wage to at
least $15 and make sure workers have the ability to join a union to
advocate for our own futures. Congress has the power to take action and
raise the standards in all nursing homes in the U.S. so that everyone--
no matter where they are from, where they live or what they do for a
living--can access high quality long term care provided by a skilled,
strong workforce that is respected, protected, and paid.
______
Questions Submitted for the Record to Adelina Ramos
Questions Submitted by Hon. Ron Wyden
Question. The Centers for Medicare and Medicaid Services (CMS)
issued an interim final rule last year that required nursing homes to
report COVID-19 data to the Centers for Disease Control and Prevention
on a weekly basis beginning May 17, 2020. These data included COVID-19
infections, COVID-19 deaths, and the availability of key equipment and
workers at individual nursing homes. The data have proved to be helpful
for the public, policy-makers, and industry stakeholders to track the
pandemic, and related issues, in these care settings. However, to date,
CMS has not required nursing homes to provide such data prior to May 8,
2020, despite calls from Senate Democrats to do so. In September 2020,
the Government Accountability Office (GAO) noted that ``by not
requiring nursing homes to submit data from the first 4 months of 2020,
HHS is limiting the usefulness of the data in helping to understand the
effects of COVID-19 in nursing homes.'' GAO went on to recommend that
``HHS, in consultation with CMS and CDC, develop a strategy to capture
more complete data on COVID-19 cases and deaths in nursing homes
retroactively back to January 1, 2020.''
Do you support GAO's recommendation? Why or why not? Please briefly
explain.
Answer. Yes, it is important for us to be able to look back at the
beginning of the pandemic to see what went wrong so that we can make
sure something like this does not happen again. Asking nursing homes to
provide information about COVID-19 infections, deaths, PPE, and
staffing for the first 4 months of 2020 will help us to understand the
timing of the pandemic's entrance into nursing homes and the nature of
its progression over time. For example, if this data shows problems
like low staffing levels or inadequate PPE, this means that measures
need to be put in place ensure adequate staffing and adequate
availability of PPE.
Question. Black women and immigrants make up a disproportionate
share of Certified Nursing Assistants and other nursing home workers--
all of whom have been hit hard by the COVID-19 pandemic. To date, more
than 550,000 nursing home workers have been infected by COVID-19, and
at least 1,600 have died. Under normal conditions, these direct care
workers conduct strenuous work at low wages, and it is not uncommon for
them to have to work double shifts, work at multiple facilities, or
take two jobs simply to make ends meet.
In your testimony, you described how your facility's staffing
issues were made worse when your coworkers were forced to stay home due
to COVID-19. The American Rescue Plan Act that President Biden just
passed provides funding for strike teams, which will provide support in
the short term for facilities with staffing issues that have been
worsened by COVID-19. However, this is a short-term solution and will
not address the ongoing issue of low wages like an increased, national
minimum wage would.
How would a $15 minimum wage help nursing home workers, and what
would the benefit be for patients?
Answer. A national minimum wage of $15 would benefit all workers,
including many who work in nursing homes. But from my experience we
will need an even higher wage to truly address the staffing crisis
among CNAs. Congress and the administration need to make sure that
Medicare and Medicaid money going to these nursing homes actually goes
to front-line staff.
First, higher wages can serve as an incentive to attract more
workers to the profession, and higher wages can also work to encourage
existing nursing home workers to stay in their positions. With more
workers entering the workforce, and less workers leaving, staffing
levels could presumably be improved. As I mentioned in my testimony, my
facility was severely understaffed at times during the pandemic and
those low staffing levels impacted resident care. Nursing home
residents, and particularly those that are critically ill, require
substantial amounts of hands-on care as they may be unable to perform
essential tasks like eating or getting out of bed by themselves.
Therefore, it is very important that CNAs are given enough time per
resident to ensure that resident needs are properly met.
Higher wages might also make it less likely that nursing home
workers have to work two or three jobs. The reason why many nursing
home workers work multiple jobs in different nursing homes to earn the
money necessary to provide for their families. If nursing home workers
could earn a living wage by working only one job, a lot more of us
would choose to only work one job. This would help residents because
workers would be less likely to travel between facilities every day,
decreasing the chance that a worker could carry an infection from one
facility to another.
In addition to higher wages, nursing home workers also deserve
pandemic pay or hazard pay during a global pandemic. During a pandemic,
the job of a nursing home worker becomes more dangerous, and therefore
deserving of additional pay. Sadly, one of my coworkers at my nursing
home passed away from COVID-19 and I contracted COVID-19 as well--
although my case was asymptomatic. Pandemic pay or hazard pay should be
guaranteed for nursing home workers during a pandemic emergency period.
Question. During the hearing, several Senators and witnesses raised
the importance of the Federal Government collecting and publishing
information from individual nursing homes that show the rate of
vaccinations for residents and staff. Since that time, a bipartisan
group of senators have sent a letter to the U.S. Department of Health
and Human Services calling on it to take steps to begin this data
collection.
As a front-line nursing home worker, would knowing this type
information affect whether you would feel comfortable working in a
given facility?
Answer. Although I was a bit hesitant to get the vaccine at first,
I am now fully vaccinated against COVID-19 and I encourage others to
become vaccinated as well. However, I do understand why some of my
colleagues are reluctant to be vaccinated. As a workforce of mostly
women and many people of color, nursing home workers have been
mistreated over the years, so it is not surprising that there are some
workers who have yet to be vaccinated. As far as knowing the
vaccination rate for a particular facility, I do think that information
is important, but I do not think vaccination rates should be used to
penalize nursing homes or nursing home workers. The vaccine should be
made available to nursing home workers at no cost, but it should be
their choice whether or not to take it.
______
Questions Submitted by Hon. Todd Young
Question. As outlined in many of your testimonies, the visiting
restrictions and isolation necessitated by the COVID-19 pandemic took a
heavy toll on the emotional and mental health of many nursing home
residents separated from their family members and other loved ones.
Fortunately, with increased vaccination and declining COVID-19 deaths,
many of these restrictions have been lifted.
While we hope that restrictions of this scale will not be necessary
again, it is worth examining ways to alleviate the negative emotional
and mental health effects that isolation may have on nursing home
residents. The use of technology, for one, has allowed residents to
interact virtually with family and other loved ones from whom they are
otherwise separated. Expanded use of telehealth has also helped
residents access routine health-care services while limiting spread of
the coronavirus.
What are some lessons learned from the public health emergency in
terms of the integration of technology in nursing homes--both in
helping residents visit virtually with loved ones and in accessing
health-care services?
Answer. When it is absolutely necessary to limit visitation in
nursing homes, video visitation technology can be useful, but its
utility should not be overstated. Many of our residents have mental
health conditions like Alzheimer's, and others have extremely limited
mobility which can limit the benefits of video visitation. And as far
as caring for residents, telemedicine can be useful, but we cannot
forget the importance of hands-on care in a face-to-face setting.
Question. How do you anticipate this type of technology continuing
to be used beyond the pandemic?
Answer. I anticipate video visitation and telemedicine to continue
to be used beyond the pandemic, where appropriate, but I do not see
these forms of technology taking the place of traditional resident
care.
______
Prepared Statement of Hon. Tim Scott,
a U.S. Senator From South Carolina
For the past year, nursing homes and other senior care providers
have served on the front lines of our Nation's pandemic response
efforts, working tirelessly to protect many of the most vulnerable
Americans from the threats posed by COVID-19. From the earliest days of
the pandemic, we have understood the heightened risks that this virus
presents to older Americans, and senior care communities have borne a
disproportionate burden. As of last month, more than one-third of
COVID-19-
related deaths in the U.S. were of long-term care facility residents
and staff. For roughly a dozen States, these individuals have accounted
for more than half of all pandemic-related fatalities. Fortunately, in
many States, government officials, health experts, and providers have
partnered to protect seniors, particularly in these facilities. In
South Carolina, for instance, Governor McMaster and our health
department acted quickly and decisively to prioritize nursing homes for
comprehensive testing, as well as to collect and publish key data
points on cases and fatalities in extended care facilities.
Unfortunately, credible evidence suggests that a number of State
governments have taken actions that have undermined our ability to
mount a response that can effectively target resources, supports, and
interventions. By ordering or otherwise encouraging nursing homes to
accept patients with active COVID-19 infections who were being
discharged by hospitals, certain States put scores of lives at risk. To
make matters worse, recent reports suggest that in New York, Governor
Cuomo's advisors actively intervened to distort data on nursing home
resident fatalities, downplaying the dire consequences of the
Governor's actions and tainting crucial data points that informed the
State's subsequent response efforts. In the case of New York, where
deaths were initially under-counted by as much as 50 percent,
inaccurate data reporting denied providers, public health experts, and
families the clarity and transparency that they deserved.
We have a responsibility to investigate and ensure accountability
for State-level actions that have jeopardized American lives and
compromised the integrity of our pandemic response efforts. I was
disappointed, earlier this year, when every Senate Democrat voted
against my proposal to ensure accurate State reporting of nursing home
resident and staff fatalities related to COVID-19. I was similarly
disappointed, earlier this month, when Senate Democrats once again
chose to oppose accountability, this time by voting against an
amendment I drafted that would have tied a portion of nursing home
strike team funding to accurate State data reporting. Every Senate
Republican voted in support of both of these common-sense measures.
Moving forward, I hope that my Democratic colleagues will join us
in advancing policies and initiatives that hold States accountable for
actions that erode public trust and harm the most vulnerable Americans.
______
Prepared Statement of Hon. Ron Wyden,
a U.S. Senator From Oregon
The U.S. is now a full year into the COVID-19 pandemic.
Vaccinations are up. Americans are beginning to feel encouraged. Yet so
many families--hundreds of thousands spread across the country--are
unable to share in the sense of uplift about what's to come because
they are mourning loved ones they've lost.
Over the last year, more than 175,000 long-term care residents and
workers, including 130,000 living and working in federally certified
nursing homes, have died of this terrible disease. They were at the
center of a collision of mismanagement. In too many nursing homes--even
before the pandemic--there was chronic understaffing, slipshod plans
for infection control, and abuse and neglect of vulnerable residents.
When COVID-19 arrived, the Trump administration came up small by
withholding data, failing to distribute PPE, and issuing guidance that
put seniors in harm's way. This was a systemic, nationwide failure, and
it will be challenging to fix. Members can start by agreeing on basic
facts.
First, what's true of the overall population is true in our nursing
homes too--blacks, Latinos, and Native Americans are suffering the
worst of COVID-19. A recent study authored by Professor Konetzka, one
of the witnesses joining the committee today, found that the loss of
life was more than three times higher in nursing homes with the highest
proportions of black and Latino residents than in facilities with
mostly white residents.
Black Americans and immigrants also make up a disproportionate
share of nursing home staff. Often they're paid low wages. More than
half a million of them have had confirmed cases of COVID-19, and
thousands have died. There's also real concern that COVID-19 will
continue to circulate among these communities where vaccines aren't as
readily available, or where uptake is lower.
These disparities in COVID-19 deaths are the result of generations
of inequity in society and in health care. Undoing it is going to take
a lot of hard work by this committee and others.
Second, the previous administration actively impeded efforts to
address long-
running problems in nursing homes. You could fill a library with the
watchdog reports calling public attention to these issues: incidents of
abuse and neglect, chronic under-staffing, squalid living conditions,
inadequate emergency preparedness, and
industry-wide failure when it comes to infection control.
Instead of addressing these issues, the Trump administration
dramatically reduced the penalties for failing to meet basic Federal
protective standards. They went out of their way to undermine any
chance at real accountability. When States rushed to develop COVID
policies, some followed Trump administration guidance that encouraged
nursing homes to accept patients regardless of whether they had tested
positive for the disease.
When the pandemic was spreading and nursing homes desperately
needed PPE, the Trump administration sent out shipments that reportedly
included loose, unusable gloves, hospital gowns that resembled trash
bags, and defective masks.
The Trump administration did not want people to know about what was
going on in nursing homes. Senator Casey and I spent months pressuring
and pleading with them to release comprehensive data. The Trump
administration stonewalled and dithered and delayed before they finally
began to relent. To this date, there is no reliable data on COVID in
nursing homes before May 1st of last year because of the Trump
administration's stonewalling.
I'll close on one final point. The terrible impact of COVID-19 on
seniors in long-term care isn't a red State or a blue State issue. It
is a nationwide tragedy. If you look at the 10 States where nursing
homes have been hit the hardest, it's five
Republican-led States and five Democratic-led States.
So the reality is, long-term care residents in all 50 States were
incredibly vulnerable to a pandemic like COVID-19 for longstanding
reasons, but the Trump administration worked harder to protect their
unscrupulous friends in management than to improve the safety of
residents themselves.
The Biden administration is already working to turn things around,
starting with ramping up vaccinations and creating strike teams of
highly trained workers who will go into nursing homes and identify
safety risks to keep residents safe.
This hearing isn't the first time or the last time that the
committee will examine nursing home safety. I want to continue working
with members of this committee, because looking after the well-being of
America's seniors is right at the heart of our jurisdiction.
______
Communications
----------
Alzheimer's Association and Alzheimer's Impact Movement
The Alzheimer's Association and Alzheimer's Impact Movement (AIM)
appreciate the opportunity to submit this statement for the record for
the Senate Finance Committee hearing entitled ``A National Tragedy:
COVID-19 in the Nation's Nursing Homes.'' The Association and AIM thank
the Committee for its continued leadership on issues important to the
millions of people living with Alzheimer's and other dementia and their
caregivers. This statement provides an overview on the long-term care
policy recommendations released by the Association and the impact
COVID-19 has had on persons living with dementia living in long-term
care facilities.
Founded in 1980, the Alzheimer's Association is the world's leading
voluntary health organization in Alzheimer's care, support, and
research. Our mission is to eliminate Alzheimer's and other dementia
through the advancement of research; to provide and enhance care and
support for all affected; and to reduce the risk of dementia through
the promotion of brain health. AIM is the Association's sister
organization, working in strategic partnership to make Alzheimer's a
national priority. Together, the Alzheimer's Association and AIM
advocate for policies to fight Alzheimer's disease, including increased
investment in research, improved care and support, and development of
approaches to reduce the risk of developing dementia.
The COVID-19 pandemic continues to create additional challenges for
people living with dementia, their families, and caregivers including
compounding the negative consequences of social isolation that many
older adults already experience. Social isolation is an issue within
the aging community as a whole, exacerbated due to the current public
health crisis, and felt particularly hard in the Alzheimer's and
dementia community.
Long-term Care, Dementia, and COVID-19
An estimated 6.2 million Americans age 65 and older are living with
Alzheimer's dementia in 2021. Total payments for all individuals with
Alzheimer's or other dementias are estimated at $355 billion (not
including unpaid caregiving) in 2021. Medicare and Medicaid are
expected to cover $239 billion or 67 percent of the total health care
and long-term care payments for people with Alzheimer's or other
dementias. Total payments for health care, long-term care, and hospice
care for people with Alzheimer's and other dementias are projected to
increase to more than $1.1 trillion in 2050. These mounting costs
threaten to bankrupt families, businesses, and our health care system.
At age 80, approximately 75 percent of people with Alzheimer's dementia
live in a nursing home compared with only 4 percent of the general
population at age 80. In all, an estimated two-thirds of those who die
of dementia do so in nursing homes, compared with 20 percent of people
with cancer and 28 percent of people dying from all other conditions.
It is critical that all residents of nursing homes, including those in
skilled nursing facilities and Medicaid nursing facilities, receive
consistent, high-quality care, especially as people can live for many
years in these settings.
At least 163,000 residents and employees of nursing homes and other
long-term care settings have died from COVID-19, representing over 30
percent of the total death toll in the United States. These communities
are on the frontlines of the COVID-19 crisis, where 48 percent of
nursing home residents are living with dementia, and 42 percent of
residents in residential care facilities have Alzheimer's or another
dementia. Residents with dementia are particularly susceptible to
COVID-19 due to their typical age, their significantly increased
likelihood of coexisting chronic conditions, and the community nature
of long-term care settings. Across the country these communities, their
staff, and their residents are experiencing a crisis due to a lack of
transparency, an inability to access the necessary testing and personal
protective equipment, incomplete reporting, and more.
To best support individuals living with Alzheimer's and dementia during
the pandemic, the Alzheimer's Association released a comprehensive set
of long-term care policy recommendations for federal and state
lawmakers, Improving the State and Federal Response to COVID-19 in
Long-Term Care Settings.\1\ These recommendations focus on four areas:
(1) rapid point-of-care testing, (2) reporting, (3) surge activation,
and (4) providing support.
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\1\ https://www.alz.org/media/HomeOffice/Downloads/Alz-LTC-Policy-
Rec_1.pdf.
These policies are designed to create a strong and decisive response to
the COVID-19 crisis in all long-term care settings and we were
heartened to see them in the American Rescue Plan Act of 2021. We thank
you for including these important provisions and strongly believe these
provisions are critical to our populations and represent a significant
step forward in improving their care during this pandemic and beyond.
Long-term Care Recommendation Specifics
We support the inclusion of dedicated funding for testing and tracing
in nursing homes and assisted living communities. All cases of COVID-19
in these settings need to be reported immediately and accurately. These
reports should be updated upon remission, death, transfer, or other
appropriate status update. With all appropriate privacy safeguards for
individuals, this reported data should be freely and immediately
accessible to all down to the facility level. It is crucial that data
on race and ethnicity are included in this reporting, which will be
especially important in ensuring targeted support for the entirety of
the COVID-19 pandemic, and preparedness for potential future pandemics.
As ``hot spots'' occur, they must be dealt with urgently and
effectively. Any reported COVID-19 cases should trigger careful,
ongoing monitoring and, if conditions warrant, well-trained and
equipped strike teams should be deployed to the facility to provide
needed support until the outbreak is contained and eliminated. All
nursing homes and assisted living communities must have full access to
all needed personal protective equipment, testing equipment, training
and external support to keep them COVID-19-free. We also strongly
support policies to increase access to televisitation technologies to
address social isolation in long-term care settings, which can have a
devastating impact, to ensure people with dementia are able to
communicate with designated family and friends.
Furthermore, now that the first safe and effective vaccines are
approved, we urge the continued prioritization of access for Americans
over the age of 65, particularly those in long-term care settings. This
is consistent with the Centers for Disease Control and Prevention's
recommendation that long-term care residents be prioritized for access
to vaccines, as well as the health care workers caring for some of the
most vulnerable in our country and who provide an enormous service to
society as a whole.
Finally, we ask that dedicated funding for home- and community-based
services continues. People living with dementia make up a large
proportion of all elderly people who use these important benefits. In
fact, 31 percent of individuals using adult day services have dementia.
Access to these services can help people with dementia live in their
homes longer and improve quality of life for both themselves and their
caregivers. For example, in-home care services, such as personal care
services, companion services, or skilled care can allow those living
with dementia to stay in familiar environments and be of considerable
assistance to caregivers. Adult day services can provide social
engagement and assistance with daily activities. Given the demands on
and responsibilities of caregivers, respite services are also critical
to their health and well-being, and may allow people with dementia to
remain in their homes longer.
Nursing Home Legislation
The Alzheimer's Association and AIM have endorsed the Nursing Home
Reform Modernization Act which would help ensure high-quality care by
establishing an Advisory Council on Skilled Nursing Facility Rankings
under Medicare and Nursing Facility Rankings under Medicaid at the
Department of Health and Human Services (HHS). This new Advisory
Council would provide HHS with recommendations on how to rank high-
rated and low-rated facilities, with information on those rankings
posted publicly to the Nursing Home Compare website. Importantly, the
Special Focus Facility Program would transition to the low-rated
facility program and Quality Improvement Organizations would work with
those low-rated facilities to improve their quality of care through on-
site consultation and educational programming. When choosing a facility
for themselves or their loved ones, families deserve to have all the
information available in a clear, easily digestible way. We appreciate
that this bipartisan bill also directs HHS to utilize focus groups and
consumer testing to ensure these ratings are easily understood by older
adults, individuals with disabilities, and family caregivers.
Conclusion
The Alzheimer's Association and AIM appreciate the steadfast support of
the Committee and its continued commitment to advancing policies
important to the millions of families affected by Alzheimer's and other
dementia. Thank you, Chairman Wyden and Ranking Member Crapo, for your
continued commitment to supporting individuals living in nursing homes
including persons living with Alzheimer's disease and other dementia.
We look forward to working with the Committee in a bipartisan way to
advance policies that would help this vulnerable population during the
COVID-19 pandemic and beyond.
______
American Geriatrics Society
40 Fulton St., 18th Floor
New York, NY 10038
212-308-1414
The American Geriatrics Society (AGS) would like to thank Chairman
Wyden, Ranking Member Crapo, and the Senate Finance Committee for their
attention to addressing the devastating impact of COVID-19 on nursing
homes and for your ongoing efforts to improve nursing home safety now
and in the future. The AGS greatly appreciates the opportunity to
submit this statement and be part of this important conversation. We
are a national non-profit organization of geriatrics healthcare
professionals dedicated to improving the health, independence, and
quality of life of all older Americans. Our 6,000+ members include
geriatricians, geriatrics nurse practitioners and advanced practice
nurses, social workers, family practitioners, physician assistants,
pharmacists, and internists who are pioneers in advanced-
illness care for older individuals, with a focus on championing
interprofessional teams, eliciting personal care goals, and treating
older people as whole persons. All of our clinician members have been
on the frontlines of caring for medically complex older adults during
the COVID-19 crisis and teaching others to do the same and more for us
all as we age. That work remains critical to ensuring we all have
access to high-quality, person-centered, affordable, and age-friendly
care as we grow older.
The ongoing public health emergency (PHE) has had a disproportionate
physical and emotional toll on older people, including nursing home and
other long-term care residents, and the frontline health workers who
care for them. Older adults and nursing home and long-term care
residents have been at substantially higher risk for serious
complications and death compared with other population
groups.\1\, \2\ As we move forward from the COVID-19
pandemic, we must address the healthcare workforce shortages and
improve the public health system to address care needs for the whole of
our population.
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\1\ Centers for Disease Control and Prevention. (2021). People at
Increased Risk: Older Adults. Available at https://www.cdc.gov/
coronavirus/2019-ncov/need-extra-precautions/older-adults.
html.
\2\ Centers for Disease Control and Prevention. (2020). People at
Increased Risk: People Who Live in a Nursing Home or Long-Term Care
Facility. Available at https://www.cdc.gov/coronavirus/2019-ncov/need-
extra-precautions/people-in-nursing-homes.html.
The AGS urges the Committee to focus on three critical areas where
attention can help achieve our vision for a United States where we are
all able to contribute to our communities and maintain our health,
safety, and independence as we age; and older people have access to
high-quality, person-centered care informed by geriatrics principles.
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These areas include:
A. Investing in the direct care workforce, which is the backbone
of our health and long-term care system.
B. Expanding support for the geriatrics health professions
programs under Title VII: Increasing funding for the geriatrics health
professions programs and ensuring that these programs are included in
public health planning efforts.
C. Investing in public health: Preparing for future pandemics,
PHEs, and disasters and ensuring public health planning involve subject
matter experts and stakeholders.
A. Investing in the Direct Care Workforce
The COVID-19 pandemic significantly exacerbated existing gaps in
expertise and systemic weaknesses in health care service delivery for
older Americans particularly for the direct care workforce.\3\ Congress
must enact federal and state policies that support the largely female
and women of color direct care workforce by increasing compensation and
benefits, strengthening training requirements and opportunities, and
creating advanced roles. Congress must also ensure that all health
professionals and direct care workers on the frontlines have access to
paid family, medical, and sick leave.
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\3\ American Geriatrics Society. American Geriatrics Society (AGS)
Policy Brief: COVID-19 and Assisted Living Facilities. J Am Geriatr
Soc. 2020;68(6):1131-1135. https://doi.org/10.1111/jgs.16510.
Direct care workers are vital to supporting older adults and their
caregivers at home and in congregate living settings (e.g., long-term
care and assisted living). They provide hands-on care at the bedside
that is physically and emotionally demanding to millions of older
Americans. At present, women account for nearly 90 percent of the
direct care workforce \4\ and women of color account for 48 percent of
this workforce in the United States.\5\ Hourly rates are low (often $12
or less per hour),\6\ and direct care workers often lack paid family
leave, and other benefits.\7\ Currently, the demand for direct care
workers exceeds the supply and this gap is only expected to grow.
Investing in building the direct care workforce should be a priority
for the United States as a part of investments in the infrastructure
that is needed to care for us all as we age.
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\4\ PHI National. (2020). Direct Care Workers in the United States:
Key Facts. Available at https://phinational.org/wp-content/uploads/
2020/09/Direct-Care-Workers-in-the-United-States-2020-PHI.pdf.
\5\ PHI National. (2017). Issue Brief: Racial and Gender
Disparities Within the Direct Care Workforce: Five Key Findings.
Available at https://phinational.org/wp-content/uploads/2017/11/Racial-
and-Gender-Disparities-in-DCW-PHI-2017.pdf.
\6\ Raghu, M. and Tucker, J. National Women's Law Center. (2020).
Low-paid Women Workers on the Front Lines of COVID-19. Available at
https://nwlc.org/blog/the-wage-gap-has-made-things-worse-for-women-on-
the-front-lines-of-covid-19/.
\7\ PHI National. (2021). Caring for the Future: The Power and
Potential of America's Direct Care Workforce. Available at https://
phinational.org/wp-content/uploads/2021/01/Caring-for-the-Future-2021-
PHI.pdf.
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B. Expanding Support for the Geriatrics Health Professions Programs
Increasing Funding for the Geriatrics Health Professions Programs
Currently, too few health workers receive adequate, if any, training in
providing the highly skilled and complex services that make care
different for older people. Furthermore, staff recruitment and
retention is particularly difficult due to the medically complex nature
of care for us all as we age. The Geriatrics Workforce Enhancement
Programs (GWEPs) and the Geriatrics Academic Career Awards (GACAs) are
the only federal mechanism for supporting geriatrics health professions
education and training. The GWEPs educate and engage the broader
frontline workforce, including family caregivers and direct care
workers, and focus on opportunities to improve the quality of care
delivered to older adults. The GACA program develops the next
generation of innovators to improve care outcomes and care delivery.
Most recently, the GWEPs and GACAs have been on the frontlines of the
COVID-19 PHE, ensuring clinical and educational training can enhance
their communities' response to the pandemic and its impacts on older
adults. The GWEPs and the GACAs are the only federal programs that
focus on training the workforce to care for older Americans and
investing in these programs is imperative to maintaining the health and
quality of life for us all as we age. At minimum, Congress should
increase annual appropriations to $51 million given the essential role
awardees play in their states.
Ensuring that Planning Bodies Include the GWEPs and GACAs in Public
Health Planning Efforts
These programs are also playing a key role in public health planning
efforts. The GWEPs and GACAs have been an asset for states especially
as many states and localities grapple with the rollout of the COVID-19
vaccine and address vaccine hesitancy. GWEPs have been staffing call
lines to assist older adults to register for the vaccine, advising
local authorities on making the sign-up websites age-friendly, and
working with health systems in the rollout of vaccines and outreach to
vulnerable and hard-to-reach populations (e.g., homebound older
Americans and Americans with disabilities). Through Project ECHO, a
telelearning and telementoring program, they have been working with
nursing homes to train staff on how to use personal protective
equipment (PPE) and on infection prevention protocols. This effort is
consistent with CMS's overall priority to reduce COVID-19 infections in
nursing homes and keep residents and staff safe during the pandemic.
Looking ahead, these programs will be critical in providing assistance
for proactive public health planning with their geriatrics expertise
and knowledge of long-term care and can help ensure states and local
governments have improved plans for older adults in disaster
preparedness for future pandemics and natural disasters. To assume
these roles, there would need to be additional investments by Congress
in both programs to ensure that states have access to the expertise of
GWEPs and GACAs. One avenue for ensuring that access is for the Health
Resources and Services Administration (HRSA) to include attention to
expertise in geriatrics and gerontology in its planning for rebuilding
the public health workforce as called for in the American Rescue Plan
Act of 2021. One way to accomplish that objective is to increase
funding to the GWEP and GACA programs with the specific goal of
ensuring that all states have access to the geriatrics education and
training that these programs provide to the healthcare workforce.
The reality is that our current healthcare workforce is ill-prepared to
care for older adults given the paucity of required training in
geriatrics across disciplines. Although AGS does not specifically track
the public health workforce, we believe it is critical that investments
be made in ensuring that this workforce understand the needs of older
Americans so that we can ensure that agencies and organizations focused
on the health of the public are meeting the needs of this large and
growing demographic group. With funding from the John A. Hartford
Foundation, Inc., the Trust for America's Health is exploring the
public health needs of older Americans with the goal of ensuring that
we are developing age-friendly public health systems.\8\ Given their
focus on developing age-friendly health systems, focus on transforming
primary care, and partnerships with community-based organizations, the
GWEPs are well-positioned to assume a greater role ensuring that as we
build up our public health workforce we are doing so in a way that
supports an age-friendly public health system.
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\8\ Trust for America's Health. (2018). Creating an Age-Friendly
Public Health System: Challenges, Opportunities, and Next Steps.
Available at https://www.tfah.org/wp-content/uploads/2018/09/
Age_Friendly_Public_Health_Convening_Report_FINAL__1___1_.pdf.
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C. Investing in Public Health
Preparing for Future Pandemics, PHEs, and Disasters
A critical area of focus should be to ensure we have plans for how to
protect the health and safety of all Americans in the event of a future
pandemic, PHE, or natural disaster. This should include assurance that
Crisis Standards of Care that dictate allocation of scarce resources do
not include discriminatory policies that are based on age alone.\9\ The
current COVID-19 PHE underscored the gaps in our planning specific to
older adults which, as in natural disasters like Hurricane Katrina,
resulted in the pandemic having a disproportionate impact on older
Americans, particularly older Americans of color. It is critically
important that the federal government review and revise PHE and
disaster guidance related to this population to provide guidance for
state and local planning.
---------------------------------------------------------------------------
\9\ Farrell T.W., et al. AGS position statement: Resource
allocation strategies in the COVID-19 era and beyond. J Am Geriatr Soc.
2020;68(6):1143-1149. https://doi.org/10.1111/jgs.16537.
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Ensuring Public Health Planning Involves Subject Matter Experts and
Stakeholders
Public health planning will necessitate coordination with several
important stakeholders and across several different priorities.\10\ We
recommend that public health planning involve subject matter experts
and stakeholders including:
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\10\ American Geriatrics Society. American Geriatrics Society (AGS)
Policy Brief: COVID-19 and Nursing Homes. J Am Geriatr Soc.
2020;68(5):908-911. https://doi.org/10.1111/jgs.16477.
a. Geriatrics health professionals should be recruited to serve on
pandemic and disaster response and planning teams, given their
expertise in caring for older people with medical complexity or
advanced illness, leading interprofessional collaboration, implementing
knowledge of long-term care across settings and sites, and leading
advance care planning. This unique skillset is essential for community-
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level planning.
b. Nursing homes and other long-term care settings leadership
teams (e.g., administrators, medical directors, and directors of
nursing) are vital for planning how resources can be best deployed
during a pandemic. These teams have expertise in allocating resources
within their own facilities; developing community-wide plans in
collaboration with acute care hospitals and other post-acute care
institutions in their communities; and building understanding of
staffing needs, as well as federal and state regulations.
c. Hospice and palliative care experts should be recruited to
serve as members of pandemic planning teams, given the need to ensure
hospitals and other facilities have access to expertise in advance care
planning, symptom management, and end-of-life care, where available.
We encourage you to consider focusing on the three critical areas while
examining COVID-19 in the nation's nursing homes.
Thank you again for the opportunity to submit this statement and for
your attention to these concerns. The AGS looks forward to continuing
to work closely with the Committee as you work to improve the lives of
all Americans.
______
Letter Submitted by Dan Arbeeny
The Honorable Ron Wyden
Chair
The Honorable Mike Crapo
Ranking Member
U.S. Senate
Committee on Finance
Washington, DC 20510-6200
RE: March 17th Hearing ``A National Tragedy: COVID-19 in the
Nation's Nursing Homes''
Chairman Wyden and Ranking Member Crapo:
My name is Dan Arbeeny and I live in Brooklyn, NY. In one week in
April 2020, we had four family members die of COVID: my father, my
uncle and two close cousins. Of the four, only one was counted as a
COVID death.
Thank you very much for scheduling this hearing on the impact of
COVID-19 on nursing homes and continuing the Committee's commendable
policy of allowing members of the public to supplement the hearing
record with additional and, in our case, personal family experience.
The scope of this nursing home debacle has already been well
described in the hearing testimony of the Government Accountability
Office (GAO) which pointed out that while ``the nation's 1.4 million
nursing home residents are a small share of the total U.S. population
(less than 1 percent), they comprise nearly 30 percent of COVID-19
deaths reported by the Centers for Disease Control and Prevention
(CDC).'' In actual numbers, this amounts to more than 174,000
individuals with the numbers still rising.
Our experience in New York, for which I claim no official role but
that of a person who has been outspoken and willing to respond to press
inquiries about how the situation in our State was made so much worse
than it had to be due to the actions of Governor Cuomo and virtually
all other aspects of the state government. I refer primarily to the
Governor's Directive of March 25, 2020 compelling the State's nursing
homes to accept COVID-19 patients.
By no means do I intend to imply that the State of New York's
nursing homes were innocent parties in this series of reckless and
wrongful actions contributing to the death of my father, other members
of our family and thousands of other New Yorkers with whom I have been
in close contact now for over a year in time. We have reluctantly
become the 100,000 New York State COVID-19 nursing home orphans.
My family has lived on the same block in Brooklyn, New York for
five generations. It is a wonderful heritage we were given, but more
importantly, it is where my family has deep community roots. My father
was a vivacious man of 88 years, still working and driving with a very
sharp mind and quick smile. He sat on the stoop of the house always
offering a smile, a greeting and keeping an eye-out for neighborhood
happenings.
Right after Christmas my father took ill and recovered, but a
series of illnesses, non-life threatening, happened that required he be
in and out of the hospital and then to a nursing home in our immediate
neighborhood called the Cobble Hill Health Center (CHHC). In short, my
Dad was doing as best he could and was COVID-free up until the time of
the Governor's disastrous March 25th Directive.
It was the CHHC which told us about the Directive and that they
were trying to persuade governor's office not to force them to take
COVID patients. Unfortunately, Governor Cuomo and the State Health
commissioner ignored their pleas. It then took us many days to move him
back home and it was during that time in CHHC that he got a low-grade
fever. Despite 24-hour care, a week later he developed congestion and
his doctor ordered a COVID test. We tested him on Monday, April 20,
2020 at 1:00pm and 12 hours later he was dead and the COVID test came
back positive afterwards.
Even as non-medical personnel, we knew it was senseless for the
State government to exercise the fullness of its powers to compel
contagious patients to the residences where the weakest and most
vulnerable were confined. What could they possibly have been thinking
and why were there not more nursing homes and their professional
associations speaking out against this ill-considered action? Instead,
the response of the State Legislature was to roll over at the
Governor's request and grant purported immunity to all the players in
this dereliction of duty.
Five days after the governor signed his March 25th Directive, the
USS Comfort and the Javits Center hospital came online giving NYC and
the surrounding area an additional 2,000 hospital beds. The Governor
did not use those facilities for patients and the general utilization
was minimal. The governor also added more regulations with regard to
the use of the Javits Center making it almost impossible to send an
elderly patient there.
Six days after the governor signed his March 25th order, the
Samaritans Purse field hospital in Central Park opened with 68 beds.
Again, for reasons which remain inexplicable, the Governor refused to
use this facility for COVID patients.
At this point we had two choices before us, give in to the grief
and anger or focus on reaching out to others in order to bring the
truth to life. We started by organizing similarly situated individuals
and doing fundraising events for Personal Protective Equipment for CHHC
and other front-line workers as well as our local police precinct.
At the same time, the media, to its credit, began to focus on CHHC
because it was reporting so many COVID deaths as part of the State
collection process. As it turned out, the reason for this was that CHHC
was the only nursing home that properly reported the number of possible
covid deaths. To the best we understood it, every other one of the 627
nursing homes significantly underreported and, of course, it was
subsequently admitted that the State itself was once again the prime
mover in this well-orchestrated cover-up.
Being so closely involved with CHHC, I spoke with many of these
reporters covering this story and it was across the full spectrum of
news outlets including News1, CNN, CBS, ABC, WSJ, Fox, AP, and many
others. There were so many that my brother Peter and I had to divide
them up in order to get out the truth of what was really happening. We
took hours to explain that CHHC was not a party at fault but that it
was the system at large and Governor Cuomo in particular who was
understating the New York death toll by midsummer at 6,500 while we had
been saying since April 2020 in over 50+ interviews including one with
Jake Tapper on CNN that the true number is more like 12,000 to 15,000
deaths.
When the news subsequently came out that the governor was writing a
book about his ``leadership'' during the COVID pandemic we knew it was
time to step up our efforts to get the actual truth out to all the
aggrieving families and other residents of New York State so they could
safeguard themselves against the March 25th Directive. We were also
hoping that the appointed and elected officials in New York as well as
the federal government would begin to take note.
On October, 18, 2020, our growing but still informal organization
hosted a Mock Funeral for Governor Cuomo's so-called ``Leadership and
Integrity'' which focused on two simple points. We asked for an apology
and that there be full admission of the true number of our loved ones
who had died in nursing homes. There was abundant press coverage which
we again appreciated in terms of trying to keep our cause alive.
We watched aghast as the Governor received an Emmy Award for what
we now know was a disastrous policy, a cynical effort to cloak it
through state-granted immunity and then a program of lying to cover it
up as long as possible. Based on what we now know, every statistic the
government used was misleading; rather than using facts to point us to
the truth, the ``guardians of the public interest'' used their offices
to point us away from the truth.
Finally, on January 28, 2021 the New York State Attorney General
belatedly announced what was considered a ``bombshell'' report
confirming that there had been a significant undercount of the number
of COVID deaths in New York nursing homes. That was followed very
quickly by the governor and State Department of Health losing in its
legal effort over reporting the COVID death data to the Empire Center
for Public Policy, an independent, non-partisan, non-profit think tank
based in Albany, NY. We likewise want to commend Judge Kimberly
O'Connor for her fortitude in that case.
Most recently and inevitably, the Secretary (Chief of Staff) to the
Governor, Mellisa DeRosa admitted at a private meeting what we had been
saying for almost a year, that the State hid the true number of deaths.
That meeting soon became public as did the next stage of the Governor's
campaign to blame everyone else.
At this point, speaking for myself and I believe almost every other
family in this situation, we have accomplished the goal of getting out
the truth. But no one in the public or private sector is admitting
their culpability for the death, distress, pain, and suffering they
have caused and concealed. We respectfully request the assistance of
this Committee in continuing its oversight and investigation of New
York State and every other state which pursued a similar program of
confining the COVID-ill to the most susceptible of the still healthy
elderly residing in Medicaid-funded nursing homes.
CONCLUSION
These are the facts as we see them from the ground:
The Governor forced 9,000 COVID-positive patients into nursing
homes in New York State;
There are 627 nursing homes in the State of New York but only
one spoke the truth;
The Governor and State Legislature wrongly sought to immunize
the medical community, hospitals, nursing homes and their associated
trade groups, management consultants, and other service providers that
assisted these companies in partnership with Governor Cuomo, the State
Department of Health and other State offices and employees;
The Governor and other State officials and private parties
knowingly and now admittedly lied to the public and impugned the
character of persons seeking to tell the truth.
Crown Publishing Group has just announced that it has ceased
promotions of the Governor's book entitled ``American Crisis:
Leadership Lessons from the COVID-19 Pandemic,'' and that there were no
plans to reprint the book or to reissue it in paperback. This is an
important first step but wholly inadequate still as the proper remedy
is for the publisher to disgorge all past and future proceeds and to
rescind the advances and any other payments made to the Cuomo in
connection with a publishing enterprise built entirely on false
pretenses. These funds should then be directed to a charitable fund in
order to help defray the burial expenses of the victims of this series
of unconscionable activities.
In addition, the Academy of Television Arts and Sciences needs to
withdraw the 2020 International Emmy Founders Award which it
inappropriately awarded to Governor Cuomo last November.
Thank you for the opportunity to submit these views.
cc: The Hon. Charles Schumer
The Hon. Kirsten Gillibrand
______
Statement Submitted by Marla Carter
Green River Area Development District (GRADD) Ombudsman Advisory
Council, Consumer Member
Faithful Friends Nursing Home Ministry leader, Pleasant Valley
Community Church
Daughter-in-law of, friend to, advocate for residents in long-term care
(LTC)
After watching the full committee hearing on March 17th, I felt
compelled to respond; first of all, with my deepest gratitude for the
issues that were discussed and the concerns that were raised, and
secondly to share my direct experiences that confirm much of what was
discussed. Having been volunteering in LTC for almost 3 years now, I
will tell you that every harrowing story and every shocking fact shared
with your committee is consistent with what I have witnessed. The long-
term care system in this country has been broken for quite some time,
and the pandemic has simply forced us to look in the mirror and finally
see the way we are caring for the elderly and disabled residents of
LTC.
My mother-in-law is a resident of a Genesis owned facility here in
Owensboro, Kentucky. Before the pandemic, our church had adopted this
facility and we were inside the facility weekly; we held Sunday school
classes, did crafts with residents, sang with residents, prayed with
them, visited with them, and often advocated for them. 60-80% of
nursing home residents never receive a single visitor; therefore, for
many residents, we became their family.
Before the pandemic, it was not unusual for us to hear residents say,
with regards to their care, ``I pushed my call button but no one
came,'' or ``I keep telling them I need to go to the doctor but they
won't make me an appointment,'' or ``they lost my favorite blanket even
though it had my name on it,'' or ``I'm out of pull-ups in my size so
they told me I have to wear a different size.''
Since the pandemic, communication has become very difficult. The
facility does not have in-room land line phones, and only a handful of
residents have personal cell phones. Most residents must go to the
nurses station to use the phone, which is hardly private and very
discouraged during the pandemic due to infection control. Even still,
here are the kinds of phone calls we've gotten now:
``There's no one to do the laundry, and I'm out of underwear, so
they put me in pull-ups.''
``It's so hot in my room but they won't let me have a fan
because it will blow the virus around.''
``We can't have showers because the steam makes the virus more
contagious. I haven't had a shower or bed bath in weeks and I smell
myself, so I know other people smell me too. I'm embarrassed.''
``I asked for a drink and they told me to get it myself.''
``Help! I'm on the toilet and I pushed the call button but no
one has come and I've been sitting here for an hour.''
``Help! They're killing me! No one will help me. Please call my
priest and tell him I'm sorry for every sin I ever committed.''
``I had an accident . . . I couldn't get to the toilet in time
so I have diarrhea all over myself. I asked for help cleaning up but
the staff told me they didn't have time because they were passing out
trays.''
``I haven't had my medicine in five days. They ordered the
refill but it hasn't come in yet.''
``I like giving my friends snacks but the staff yells at me and
says I have to stay in my room all the time. I feel like I'm in a
communist country.''
``The staff told me I'm a troublemaker. Do you think I'm a
troublemaker?''
``The traveling nurse gave me the wrong medicine and I had a
really upset stomach. She told me not to tell you.''
``I told the staff that my roommate had a fever and was sick but
they told me to mind my own business.''
Keep in mind that we have an excellent relationship with this facility.
The administrator has been very supportive and tries very hard to
ensure residents are cared for with compassion and dignity. But she can
only work with what she's given by corporate--low wages and the
inability to hire more staff--and she can't be there all the time.
Even in the midst of the pandemic, when they were receiving more
federal and state funds, I did not see an impact on patient care. For
example, this facility received nearly the maximum amount of civil
monetary penalty funds for improving virtual communication in the
summer of 2020. It's unclear to me exactly what that money was spent
on, though presumably it was spent on new iPads. My experience, though,
was that staff didn't know how to set up the iPads/Facetime and even
when they figured it out, there were only 4 for the building and they
had to be shared; residents had to wait for a staff person to bring
them an iPad and help them with it. Some residents used them to watch
religious services online, and a few virtual ``visits'' were scheduled
for Mother's Day and birthdays.
A few cell phones were purchased so that each unit would have a phone
that could be taken to resident rooms instead of them having to use the
phone at the nurses station. However, those phones quickly got lost.
The activities director went above and beyond to try to keep residents
entertained, though she was limited with her resources as well. Here
are all the things our church donated to the facility because they
couldn't buy them:
Shepherd's hooks (to hang bird feeders outside residents'
windows);
5 CD players (because each wing had to have its own because they
weren't allowed to carry their one CD player wing to wing due to
infection control);
Craft supplies: construction paper, glue, markers, crayons, old
magazines, paint, cereal boxes, buttons, wrapping paper, note cards,
pumpkins; and
Misc items: 10 sets of drum sticks, 10 large stability balls, 10
laundry baskets, printable games, puzzles, activity pages, Scripture
hand outs, Bibles, devotionals, library books, CDs, DVDs, VHS tapes,
television
Other items we have donated:
Clothing, shoes, socks;
Gift bags for all residents containing snacks, puzzle books,
markers, tumblers, lotion, shampoo, hairbrush, tissues, soft candy,
pens, notepads (twice yearly); and
In the past year, our church spent $5,000 on things for this
facility--some of that money went for treats for the staff to encourage
them. This figure would be much higher if we factored in what folks
from our church donated--hundreds of dollars in Christmas gifts and
toiletries.
While you would expect that a facility that charges nearly $8,000/month
could supply the most basic of things, we are constantly amazed at how
many residents are impoverished and needy. We have brought clothing to
residents who had only one change of clothes and pajamas to residents
who only had a hospital gown. Residents often run out of tissues, pull
ups, and personal hygiene items. (Most residents are on Medicaid and
thus only receive a $30 allowance each month. Their $30 is all they
have for things like haircuts, snacks, clothing, anything ``extra.'')
You would also expect that such a facility would have a doctor on site
at all times; after all, this is a skilled nursing facility that cares
for some very acutely ill residents. However, there is only a nurse
practitioner on site Monday-Friday. The ``medical director'' is a local
physician who works on the side to ``oversee'' the medical care the
nurse practitioner is providing. He checks in periodically and comes in
a few times a month to check over the charts. He is listed as my
mother-in-law's primary care physician, yet when I have a question
regarding her care, I cannot call him on the phone to discuss her care.
Another thing you might expect from such a facility is that they would
provide transportation for residents to and from doctor's appointments
or even for ``fun'' outings. No. This facility does not have a vehicle/
bus/van. When residents leave to go to a medical appointment, they must
ride on the local GRITS bus (Green River Intra-County Transit System),
which is a free or low-cost public transportation service- free for
persons receiving Medicaid and low cost to the general public.
One terrible example of facilities relying on this service involved a
92 year-old ward of the state who was being transferred from one
skilled nursing facility to another in mid-July. She was transferred on
the GRITS bus, wearing a black sweat suit and no shoes (socks only)
with none of her belongings except her Bible. It was weeks before she
had any of her belongings delivered to her because each facility
claimed not to know which one was responsible for transporting her
things, and both used the excuse that they did not have a facility
vehicle. Additionally, during the pandemic, facilities are still
relying on this public transportation--residents that had to leave
regularly for dialysis or other regular appointments were not allowed
to ride in a family member's car--they had to use the GRITS bus, though
their family member was allowed to meet them at the appointment.
Illogical!
We have gotten creative during the pandemic to find ways to continue to
help the residents and the facility, but we dearly miss the residents
and they miss us. I have asked corporate repeatedly to allow us to
continue to volunteer, even outdoors if preferable. This facility, like
so many others, has struggled to maintain its staff. They've had a
great deal of turnover and are always in need of more staff. They did
hire some emergency ``unit aide'' people, who were untrained but came
in for a few months to help with basic, non-medical tasks. These are
things we could have been doing for free! Before the pandemic, we were
in many ways, ``staff extenders.'' Here are some things we did:
Wheeled residents to the dining hall;
Sat with residents and encouraged them eat;
Helped them get a different food choice if they didn't like what
was served;
Got them water/drinks (with staff direction- we knew who had
fluid restrictions, etc);
Helped locate lost items in the laundry room;
Helped write names in/on resident belongings;
Helped locate lost items in rooms (glasses, dentures, remote
controls, etc);
Helped fix TVs, phones, radios, etc.;
Went to the store for residents;
Assisted with holiday parties and crafts;
Scheduled extra fun activities for residents (for example we had
a sweet girl from our church who has no arms come in and paint for the
residents with her feet--they loved her!!);
Held weekly Sunday school classes for residents;
Helped residents make phone calls;
Helped re-direct residents who were wandering; and
Sat with residents who were upset, talked with them.
These are all very important tasks that the staff simply does not have
time to do because they are stretched too thin. This summer, when
outdoor visits began to be allowed, we offered to come assist with
screenings at the door and supervising the visits outside, but were
told no. As of today, we are still not allowed inside. Our ministry
team of volunteers has been vaccinated and so have over 90% of the
residents, while only 50% of staff have been vaccinated. We would like
to come inside and help!! If untrained employees could be hired for
extra help in the middle of the pandemic, why can't we now enter and
help. We can go through the same screenings as staff and be trained in
infection control practices. Our services are free and contribute
greatly to residents' quality of life! So why would corporate not allow
us inside to help at a time when they cannot keep staff?
When we first started visiting my mother-in-law and other residents in
the nursing home, I was shocked by the conditions. Since then, I've
done much reading about Medicare certified facilities, the care they
provide, and the great expense they are to the taxpayer and the
government. For example:
``The vast majority of nursing homes reap substantial funding
from Medicare and Medicaid in exchange for the promise of providing
quality care to their patients. In fact, a 2015 CMS report found that,
in 2014, of the 15.634 nursing homes across the US, 92.2% (14,407) were
dually certified to receive both Medicare and Medicaid payments. In
other words, federal government taxpayer funding pays for most nursing
home care. And the truth is that these nursing home corporations rely
upon this steady course of income--government payments--to generate
profit. Many, in fact, generate very substantial profits from it.''
In 2009 alone, one out of every four claims submitted by the US
nursing home industry was erroneous, resulting in $1.5 billion worth of
unjustified payments from Medicare.
A 2015 article entitled ``Nursing Home Care Industry Is a Solid
Investment,'' pointed out the virtues of investing in the nursing home
industry: ``Profits are staggering, and the nursing home companies have
a long time of add-on sales for supplemental services through
subsidiaries they control.'' (Dr. Harold Goldmier, investment
strategist, 2015)
The modern American nursing home grew out of the 19th-century
almshouse, a kind of public, charitable organization that was set up to
help the ``worthy poor'' (originally, widows of good social standing
who had fallen into destitution). The almshouse system expanded until
the 1930s, when officials at the United States Social Security Board
began to worry about the ``increasing dependency'' of ``the aged'';
they feared that old people would bankrupt the country with their
expensive infirmities. They made efforts to shut the facilities down,
and they proposed that the government start a small pension, what would
become Social Security benefits.
In place of the almshouses came pay-to-stay ``rest homes'' and,
later, more medically staffed nursing homes, all competing in a private
marketplace for elder care. By 2000, nursing homes were a $100 billion
business, and the little mom and pop shops that had once dominated the
industry were being fused together and swallowed up into larger
entities. For a time, it seemed like nothing could stop the growth. It
didn't matter when, in the early 2000s, five of the country's top-ten
nursing-home chains entered into Chapter 11 bankruptcy proceedings
after undertaking a string of heavily debt-financed mergers and
acquisitions. The companies were restructured, and sometimes rebranded,
and then continued on their way. Today, around 70 percent of nursing
homes are for-profit, and more than half are affiliated with corporate
chains.
All the while, nursing-home chains continued to get bigger,
until just five companies owned more than 10 percent of the country's
1.7 million licensed nursing home beds. Private equity also entered the
sector, buying up four of the ten largest for-profit nursing homes.
``There's essentially unlimited consumer demand as the baby boomers
age,'' Ronald E. Silva, president of Fillmore Capital Partners, told
The New York Times in 2007, after paying $1.8 billion to purchase a
large nursing-home chain called Beverly Enterprises Inc. ``I've never
seen a surer bet.'' These new ownership groups changed things in ways
that people who lived in them could feel. Earlier this year, a Wharton
School--New York University--University of Chicago research team found
``robust evidence'' that private-equity buyouts lead to ``declines in
patient health and compliance with care standards.'' When nursing homes
are bought by private-equity groups, the team concluded, frontline
nursing staff are cut, and residents are more likely to be
hospitalized.
But the most consequential change may have happened within the
for-profit companies themselves. It all started, most undramatically,
with a 2003 academic article in The Journal of Health Law. In
``Protecting Nursing Home Companies: Limiting Liability Through
Corporate Restructuring,'' its authors--two health-care lawyers--made
note of two financial threats to nursing-home operators: lawsuits by
nursing-home residents (for, say, negligence) and efforts by the
government to recoup overpayments (for, say, false claims on Medicare
billings). The solution, the authors suggested, was in restructuring.
Specifically, nursing homes should split up into separate limited-
liability corporations, one for real estate and one for operations.
This new structure, they wrote, would keep assets safe from litigious
family members and retributive bureaucrats. It would also attract money
from real-estate investors who were keen on nursing homes but wary of
the liability risks. By 2008, the top-ten companies had all split
themselves into real estate and operations LLCs.
Then many companies went further, creating networks of sub-
companies called ``related parties'' that could trade and transact with
one another. What had once been a nursing home became a corporate
cluster, including separate entities for real estate, insurance,
management, consulting, medical supplies, hospice, therapy, private
ambulances, and pharmacy services. By 2017, three-quarters of nursing
homes did business with related parties, according to a study by Kaiser
Health News. There was nothing inherently wrong, and certainly nothing
illegal, about these increasingly complex formulations. The owners said
that they were only creating a vertical supply chain for eldercare. By
2015, nursing homes were spending $11 billion a year on contracts with
related parties.
But the structure had an additional benefit that the authors of
the article had not pointed out: It allowed companies to siphon profits
out of their nursing homes through sometimes exorbitantly overpriced
transactions with their sister companies. Instead of hiring salaried
managers to oversee a facility, a nursing home could now contract with
expensive related-party management corporations and consultancies.
Instead of owning the land around a nursing home, a company could lease
it from a related-party real-estate business, sometimes at a higher-
than-market rate. In this way, a nursing home could appear, on its
accounting sheets, to be operating on slim margins, or even at a loss,
but only because that loss was offsetting gains within the same
company.
``No one begrudges a company for making profits,'' Dr. Michael
Wasserman, president of the California Association of Long-Term Care
Medicine, told me. ``This is capitalism. This is America.'' The issue,
he said, is that doctors and nurses are pressed to cut costs while
related parties are getting rich. ``If the real-estate entity is making
significant profits and the operation is break-even, then there's a
problem. I would compare today's nursing-home real-estate owners to
slumlords.'' This excerpt is from an article that appeared here:
https://story.californiasunday.com/covid-life-care-center-kirkland-
washington?fbclid=Iw
AR24x0cPBI-v3I37CIJpKr0R729Ew9OZ_AfOGUnjE7wHrB-4pLd18r00YIQ.
A 2014 report by the Office of the Inspector General of the
Department of Health and Human Services about adverse events in skilled
nursing facilities found that one in three patients who stay in a
nursing home will suffer harm or injury within the first 35 days as a
result of the care they receive. The report also found that most of
these incidents are ``clearly or likely preventable,'' and attributed
much of the preventable harm to ``substandard treatment, inadequate
resident monitoring, and failure or delay of necessary care.''--
Levinson, Office of Inspector General, 2014
In the above report, 66% of these harmful events were due to
preventable medication errors. The report further found an estimated
7,203 hospitalizations for medication events, which on average, cost an
estimated $8,372. The estimated total spending related to
hospitalizations for medication events was an estimated $57,729,935--
just for the month of August 2011. (That is NOT a typo!)
The nursing home setting is a significant risk factor for sexual
abuse. A study of elder sexual abuse in Virginia from 1996 through 2001
which researched sexual abuse in both institutional and residential
settings found that nearly three-quarters of all sexual abuse occurred
in nursing homes. (Teaster and Roberto, 2005) In other words, an
elderly person is in more danger in a nursing home than on the streets
of a typical U.S. city.
Pressure sores have long been established as an indicator or
substandard care. CMS identifies stages III and IV pressure sores as
being one of eight preventable conditions. In 2004, more than one in
ten nursing home residents had a pressure sore (NCHS, Park-Lee &
Caffrey). The total annual cost for treating pressure sores in the US
is $11 billion (Institute for Healthcare Improvement, 2007).
No doubt, the patients and their families are the primary
victims, but clearly, lower-level nursing home staff are victimized by
the industry's obsession with profits as well. As if being stressed,
overworked, and forced by circumstances to mistreat patients weren't
enough, the median annual wage of nursing aides and orderlies working
in nursing homes is $24,7000 and $19,950 to $22,580 respectively (U.S.
Bureau of Labor Statistics, 2016-2017). Effectively, the working poor,
who are themselves among the most vulnerable in our society, are the
ones taking care of elderly, vulnerable patients. Each is being taken
advantage of by the nursing home industry.--Abuses and Excuses: How to
Hold Bad Nursing Homes Accountable, by Jeffrey Powless.
In my humble opinion, not only are many nursing homes committing
Medicare/
Medicaid fraud by failing to provide the services for which they are
receiving federal funds, but also by then receiving more money from the
government and the taxpayers to take care of the additional health
problems that their negligence has created. It's akin to double
billing!
It is my firm belief that most all of the issues within the nation's
nursing homes can be boiled down to staffing. They don't hire enough
and they don't pay enough. However, providers are going to tell you
they can't find employees, or that they need more Medicare/Medicaid
reimbursements in order to hire more and pay more. I just don't believe
that's true. I think the way they have been allowed to structure their
corporations with private equity firms controlling the various
intertwined entities of real estate, vendors, and goods is the real
problem. I have seen non-profit facilities and the difference in care
they provide is remarkable.
If you would like further reading on these issues, here are some
resources I have found helpful:
https://www.amazon.com/Abuses-Excuses-Nursing-Homes-Accountable-ebook/
dp/B075P8DS4V
https://www.amazon.com/Being-Mortal-Medicine-What-Matters/dp/0805095152
https://story.californiasunday.com/covid-life-care-center-kirkland-
washington?fbclid
=IwAR24x0cPBI-v3I37CIJpKr0R729Ew9OZ_AfOGUnjE7wHrB-4pLd18r00YIQ
https://www.sentinel-echo.com/news/nursing-homes-had-problems-
controlling-infections-before-covid-19/article_7ae9804e-8e1b-11ea-8c5a-
a36127b9d3fb.html
https://www.marketwatch.com/story/covid-19-devastated-nursing-homes-
here-are-safer-more-cost-effective-options-11602245129
https://www.wsws.org/en/articles/2020/04/27/nur2-a27.html
https://nurse.org/articles/nurse-staffing-unsafe-long-care-facilities/
______
Statement Submitted by Eilon Caspi, Ph.D.
On June 13, 2019, the GAO released the report: Nursing Homes: Improved
Oversight Needed to Better Protect Residents From Abuse. The GAO's
investigation reported that CMS does not track ``abuse perpetrator
type'' (such as staff or residents) in over 15,000 nursing homes
nationwide. It urged CMS to bridge this major gap in oversight of
nursing homes.
Two years prior to the GAO 2019 report, I published an extensive
article in the Journal of Elder Abuse and Neglect identifying this gap
including 20 reasons why it needs to be addressed by CMS.
Caspi, E. (2017). A federal survey deficiency citation is needed for
resident-to-
resident aggression in U.S. nursing homes. Journal of Elder Abuse and
Neglect, 29(4), 193-212.
In addition, the MDS 3.0, which is the largest federally-mandated
clinical dataset in nursing homes also doesn't track resident-to-
resident incidents:
Caspi, E. (2013). M.D.S. 3.0--A giant step forward but what about items
on
resident-to-resident aggression? Journal of the American Medical
Directors Association, 14(8), 624-625.
When this public health problem is not being tracked, for all practical
purposes, it does not exist and CMS is not in a position to learn from
these incidents to inform nationwide prevention. These injurious and
deadly incidents remain invisible.
I've been focusing on the prevention of this prevalent and disturbing
phenomenon of injurious and deadly neglect for over 13 years. For
example, I published the first study in the U.S. on fatal resident-to-
resident incidents:
Caspi, E. (2018). The circumstances surrounding the death of 105 elders
as a result of resident-to-resident incidents in dementia in long-term
care homes. Journal of Elder Abuse and Neglect, 30(4), 284-308.
An early Harvard study showed that injurious resident-to-resident
incidents are prevalent in U.S. nursing homes:
Shinoda-Tagawa et al. (2004). Resident-to-resident violent incidents in
nursing homes. JAMA, 291(5), 591-598.
I've also co-directed the first documentary film on this phenomenon.
The film is entitled Fighting for Dignity and it was produced by Terra
Nova Films (released in early 2020).
My book, the first on the prevention of these incidents, will be
published by Health Professions Press this summer.
Over the years, I've reviewed several hundred injurious and deadly
resident-to-
resident incidents and came to learn that the vast majority of these
incidents, especially in the context of resident with a serious brain
disease such as Alzheimer's disease, are a form of neglect such as the
neglect of meeting residents psychological and medical needs and
neglect of supervision.
When I saw the GAO 2019 report and the aforementioned recommendation in
it, I was hoping that CMS will finally require all 50 State Survey
Agencies to track ``abuse perpetrator type'' (staff-to-resident abuse
and resident-to-resident incidents).
However, nearly 20 months after the GAO report was released, CMS has
yet to bridge this major gap in its oversight and enforcement
activities of nursing homes. This, despite the fact that HHS concurred
with the GAO recommendation.
Residents continue to be injured and die due to these resident-to-
resident incidents--even during the pandemic. It is important to point
out that the majority of these incidents are preventable.
Would your committee consider urging CMS to implement the GAO 2019
recommendation?
Specifically, this was GAO's ``priority'' recommendation:
``The administrator of CMS should require that abuse and perpetrator
type be submitted by state survey agencies in CMS's databases for
deficiency, complaint, and facility-reported incident data, and that
CMS systematically assess trends in these data. (Recommendation 1).''
This was CMS response to the GAO recommendation:
``HHS concurred with this recommendation. In February 2020, HHS said
CMS is developing the ability to review survey trends related to
alleged perpetrator and alleged abuse types and aims to implement this
recommendation by December 2020.''
The son of 87-year-old resident who had Alzheimer's disease and died
four days after a resident with dementia pushed him and caused him to
hit his head on the floor and sustain a blunt head trauma (determined
in autopsy as the cause of death) said:
``We want to see a solution. We do not want the death of our
father to be in vain . . . We are out to find a solution. To
make sure that our aging population is taken care of. I want to
see something done so this doesn't happen again''
Thanks for your consideration,
Yours sincerely,
Eilon Caspi, Ph.D.
Gerontologist and Dementia Behavior Specialist
Assistant Research Professor
Institute for Collaboration on Health, Intervention, and Policy
University of Connecticut
Website: https://chip.uconn.edu
Adjunct Faculty
School of Nursing
University of Minnesota
Website: https://www.nursing.umn.edu
Founder and Director
Dementia Behavior Consulting LLC
Website: http://dementiabehaviorconsulting.com
Founding Member and Board Member
Elder Voice Family Advocates
Website: https://www.eldervoicefamilyadvocates.org
Board Member
Long-Term Care Community Coalition, NYC
https://nursinghome411.org
Editorial Board Member
Journal of Elder Abuse and Neglect
Author of the upcoming book: Understanding and Preventing Harmful
Interactions Between Residents with Dementia. Health Professions Press.
Scheduled release: Summer 2021.
Director of Documentary Film: ``Fighting for Dignity: Prevention of
Harmful Interactions Between Residents with Dementia in Long-Term Care
Homes.'' Terra Nova Films.
Webpage: https://tinyurl.com/td826r9
______
Center for Fiscal Equity
14448 Parkvale Road, Suite 6
Rockville, MD 20853
[email protected]
Statement of Michael G. Bindner
Chairman Wyden and Ranking Member Crapo, thank you for the opportunity
to submit these comments for the record to the Subcommittee. I will not
pull any punches.
This crisis is worse than you think. For whatever reason, the
Coronavirus Task Force has ignored the first round of symptoms of this
ailment. In my experience, it begins as a cold with heavy mucus. Bad
timing made many sufferers believe that they had merely suffering from
hay fever. There is then a week of dormancy. If you assume that
exposure occurs 2 weeks prior to the first symptoms, there are four
weeks, rather than two, before SARS symptoms are manifested, including
fever, fatigue from low oxygen levels and fatigue from the manufacture
of immunity (which feels like a gut punch over a 2-week period).
Ignoring the early symptoms in CDC guidelines means that, even with the
best of care, the pandemic can blow through the nursing population
before anyone realizes that COVID is running amok. The continuing
denial of this model means that the disease will continue unabated
until it runs out of vectors--meaning that vulnerable patients will
continue to die until vaccinated.
On the positive side, our experience is that once one has marked
symptoms, full immunity is most likely. Young people, who laughed off
the early symptoms of the virus or simply did not experience it, are
now getting sick. This could lead to another round of reinfection in
nursing homes staffed with younger workers. Older workers, who likely
have had symptoms, are now safer care givers for the elderly.
One of the developments no one talks about is the shedding of PPE.
Healthcare workers see patients when they are after the contagious
stage. Heavy PPE frightened people with the virus in the first wave had
them avoid care until it was too late. Publicizing this will get people
into care faster. Fearing death becomes a self-fulfilling prophecy when
care given early will save lives.
Getting nursing home patients into a hospital setting will preserve
their lives. Leaving their care to nursing home staff, especially when
the disease is first evident, means that residents will get care from
rookies. This is not a disease that tolerates mistakes in care.
COVID mortality has hastened death for older victims. Those who would
have died of a heart attack within the next five years likely died this
past year. We will see how high COVID deaths reach in comparison to
heart attack death for the year. I suspect the latter will be down and
the former may be second to cancer, if not the number one cause of
death this year.
In comments provided to congressional committees last summer, I
predicted at least 120 deaths per 100,000 individuals in the
population. I had assumed that the nation would have done better than
New York, which at the time had 150 deaths per 100,000. If mortality
mirrors New York from that period, 500,000 people would have died. We
have exceeded the more pessimistic estimate by tens of thousands.
Careful chart review will likely show under-reporting, so true death
rates may turn out to approach 1,000,000 deaths. Let this sink in for a
moment.
This virus originally did not hurt younger people. The latest variant
is now making them very ill, but is less likely to kill them. By the
time vaccines are available to them, they will have already been ill.
The science is now showing that children have more robust immune
systems. To them, COVID-19 is just another cold virus to fight off.
Their immune systems are in high gear. For this reason, vaccinating
them will be a mistake. They need to build their immune systems by
getting sick and recovering. Robbing them of this experience leaves
them vulnerable to the next pandemic. They need to play in the dirt and
with each other, even when sick. Colds are not Ebola. Treating it as
such is counter-survival for the species.
Why were older people more vulnerable at first? Older citizens are
farther away from having colds and being exposed to them. Current
precautions also degrade immunity because it is not challenged. This is
also why Influenza is so dangerous to nursing home residents. Older
citizens who are not in a nursing home, especially those in a multi-
generational household, are less likely to become sick, primarily
because their immune systems are challenged by their snot-nosed
grandchildren.
Any parent will confirm that their younger children are constantly sick
and that they share the pain--much to the horror of co-workers--
although having sick parents come to work also spreads manageable
illness. Being shielded, however, leaves one vulnerable to symptoms. My
daughter is with her mother in Knoxville. I got sick. My ex-wife
probably will not, especially as she has just had her second shot.
A major problem in getting care is our insurance system. A single-payer
system, either through a public option, Medicare for All or cooperative
care through employee-owned and provided medicine, including nursing
homes, will save lives in the next pandemic.
The attachment presented in 2019 is still as timely as it was then.
Even more so, since it covers the public option within the Affordable
Care and American Recovery Acts. If pre-existing conditions were
repealed, for profit insurance would move more people to the public
option each year, which would be their undoing. Single-payer health
care as part of a bailout of the industry would be the natural result.
A recent paper by the National Bureau of Economic Research asking
``Does Private Equity Investment in Healthcare Benefit Patients?
Evidence from Nursing Homes'' is essential in addressing this issue. I
commend it to your attention. You can find it online at https://
www.nber.org/papers/w28474.
Thank you for the opportunity to address the committee. We are, of
course, available for direct testimony or to answer questions by
members and staff.
Attachment--Single-Payer, June 12, 2019
There is no logic in rewarding people with good genes and punishing
those who were not so lucky (which, I suspect, is most of us). Nor is
there logic in giving health insurance companies a subsidy in finding
the healthy and denying coverage for the sick, except the logic of the
bottom line. Another term for this is piracy. Insurance companies, on
their own, resist community rating and voters resist mandates--
especially the young and the lucky. As recent reforms are inadequate
(aside from the fact of higher deductibles and the exclusion of
undocumented workers), some form of single-payer is inevitable. There
are three methods to get to single-payer.
The first to set up a public option and end protections for pre-
existing conditions and mandates. The public option would then cover
all families who are rejected for either pre-existing conditions or the
inability to pay. In essence, this is an expansion of Medicaid to
everyone with a pre-existing condition. As such, it would be funded
through increased taxation, which will be addressed below. A variation
is the expansion of the Uniformed Public Health Service to treat such
individuals and their families.
The public option is inherently unstable over the long term. The profit
motive will ultimately make the exclusion pool grow until private
insurance would no longer be justified, leading again to Single Payer
if the race to cut customers leads to no one left in private insurance
who is actually sick. This eventually becomes Medicare for All, but
with easier passage and sudden adoption as private health plans are
either banned or become bankrupt. Single-payer would then be what
occurs when
The second option is Medicare for All, which I described in an
attachment to yesterday's testimony and previously in hearings held May
8, 2019 (Finance) and May 8, 2018 (Ways and Means). Medicare for All is
essentially Medicaid for All without the smell of welfare and with
providers reimbursed at Medicare levels, with the difference funded by
tax revenue.
Medicare for All is a really good slogan, at least to mobilize the
base. One would think it would attract the support of even the Tea
Partiers who held up signs saying ``Don't let the government touch my
Medicare!'' Alas, it has not. This has been a conversation on the left
and it has not gotten beyond shouting slogans either. We need to decide
what we want and whether it really is Medicare for All. If we want to
go to any doctor we wish, pay nothing and have no premiums, then that
is not Medicare.
There are essentially two Medicare's, a high option and a low one. One
option has Part A at no cost (funded by the Hospital Insurance Payroll
Tax and part of Obamacare's high unearned income tax as well as the
general fund), Medicare Part B, with a 20% copay and a $135 per month
premium and Medicare Part D, which has both premiums and copays and is
run through private providers. Parts A and B also are contracted out to
insurance companies for case management. Much of this is now managed
care, as is Medicare Advantage (Part C).
Obamacare has premiums with income-based supports and copays. It may
have a high option, like the Federal Employee Health Benefits Program
(which also covers Congress) on which it is modeled, a standard option
that puts you into an HMO. The HMO drug copays for Obamacare are higher
than for Medicare Part C, but the office visit prices are exactly the
same.
What does it mean, then, to want Medicare for All? If it means we want
everyone who can afford it to get Medicare Advantage Coverage, we
already have that. It is Obamacare. The reality is that Senator Sanders
wants to reduce Medicare copays and premiums to Medicaid levels and
then slowly reduce eligibility levels until everyone is covered. Of
course, this will still likely give us HMO coverage for everyone except
the very rich, unless he adds a high-option PPO or reimbursable plan.
Either Medicare for All or a real single payer would require a very
large payroll tax (and would eliminate the HI tax) or an employer paid
subtraction value added tax (so it would not appear on receipts nor
would it be zero rated at the border, since there would be no evading
it), which we discuss below, because the Health Care Reform debate is
ultimately a tax reform debate. Too much money is at stake for it to be
otherwise, although we may do just as well to call Obamacare Medicare
for All.
The third option is an exclusion for employers, especially employee-
owned and cooperative firms, who provide medical care directly to their
employees without third party insurance, with the employer making HMO-
like arrangements with local hospitals and medical practices for
inpatient and specialist care.
Employer-based taxes, such as a subtraction VAT or payroll tax, will
provide an incentive to avoid these taxes by providing such care.
Employers who fund catastrophic care or operate nursing care facilities
would get an even higher benefit, with the proviso that any care so
provided be superior to the care available through Medicaid or Medicare
for All. Making employers responsible for most costs and for all cost
savings allows them to use some market power to get lower rates.
This proposal is probably the most promising way to arrest health care
costs from their current upward spiral--as employers who would be
financially responsible for this care through taxes would have a real
incentive to limit spending in a way that individual taxpayers simply
do not have the means or incentive to exercise. The employee-ownership
must ultimately expand to most of the economy as an alternative to
capitalism, which is also unstable as income concentration becomes
obvious to all.
The key to any single-payer option is securing a funding stream. While
payroll taxes are the standard suggestion, there are problems with
progressivity if such taxes are capped and because profit remains
untaxed, which requires the difference be subsidized through higher
income taxes. For this reason, funding should come through some form of
value-added tax.
Timelines are also concerns. Medicare for All be done gradually by
expanding the pool of beneficiaries, regardless of condition. Relying
on a Public Option will first serve the poorest and the sickest, but
with the expectation that private insurance will enlarge the pool of
those not covered until the remainder can safely be incorporated into a
single-payer system through legislation or bankruptcy.
______
Center for Medicare Advocacy
1025 Connecticut Avenue, NW, Suite 709
Washington, DC 20036
(202) 293-5760
Statement of Toby S. Edelman, Senior Policy Attorney
The Center for Medicare Advocacy is a national non-profit law
organization founded in 1986. The Center provides legal assistance,
education, analysis, and advocacy to advance access to comprehensive
Medicare coverage and high quality care for older people and people
with disabilities. The Center focuses on the concerns of people with
chronic conditions and those in need of long-term care. The
organization's positions and actions are based on the experiences of
the people we hear from every day.
Thank you for holding this important hearing on COVID-19 in the
nation's nursing homes. The experience of COVID-19 is indeed a national
tragedy. Although the early days of the coronavirus pandemic were
especially chaotic, when little was known about asymptomatic spread of
the virus, there is no question that better staffing and infection
control practices could have prevented, and, in some facilities, did
prevent, many cases and deaths among residents and staff.\1\
---------------------------------------------------------------------------
\1\ Cinnamon St. John, ``Geography Is Not Destiny: Protecting
Nursing Home Residents from the Next Pandemic'' (Feb. 2021), https://
medicareadvocacy.org/wp-content/uploads/2021/02/CMA-NH-Report-
Geography-is-Not-Destiny.pdf.
The coronavirus pandemic has exacerbated longstanding problems in the
nation's nursing homes and brought them all too vividly to national
attention. These problems must be corrected to ensure that the next
public health crisis does not result, again, in such devastation,
overwhelming loss of life, and serious harm to residents' health and
quality of life.\2\
---------------------------------------------------------------------------
\2\ Michael Levere, Patricia Rowan, Andrea Wysocki, ``The adverse
events of the COVID-19 pandemic on nursing home resident well-being,''
Journal of the American Medical Directors Association (Journal Pre-
proof published Mar. 2021), https://www.jamda.com/article/S1525-
8610(21)00306-6/pdf (documenting negative consequences of pandemic on
Connecticut nursing home residents, including increases in depression,
unplanned weight loss, and incontinence and deterioration in cognitive
function, resulting from residents' loneliness and isolation).
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Longstanding Problems
1. Inadequate nurse staffing levels, both professional and
paraprofessional
The lack of sufficient numbers of nursing staff has been known for
decades. In 2000, a federal study mandated by the 1987 Nursing Home
Reform Law documented that more than 90 percent of nursing facilities
did not have sufficient staff to prevent avoidable harm or to meet
standards of care set out in the Reform Law.\3\ Staffing levels have
not changed in the two decades since the report was issued, despite the
increased frailty and acuity of the resident population.
---------------------------------------------------------------------------
\3\ CMS, Report to Congress: Appropriateness of Minimum Nurse
Staffing Ratios (2001).
The coronavirus pandemic has continued to highlight the dire
consequences of inadequately staffing nursing facilities. Study after
study documents that facilities without sufficient nursing staff have
both more cases of COVID-19 and more deaths from the virus.\4\ A study
of nursing facilities in Connecticut found that 20 minutes of
additional registered nurse care per resident per day was correlated
with 22% fewer COVID-19 cases among residents and 26% fewer deaths.\5\
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\4\ CMA Alert, ``Studies Find Higher Nurse Staffing Levels in
Nursing Facilities Are Correlated With Better Containment of COVID-19''
(Aug. 13, 2020), https://medicareadvocacy.org/studies-find-higher-
nurse-staffing-levels-in-nursing-facilities-are-correlated-with-better-
containment-of-covid-19/ (citing multiple studies). See also Jose F.
Figueroa, Rishi K. Wadhera, Irene Papanicolas, et al, ``Association of
Nursing Home Ratings on Health Inspections, Quality of Care, and Nurse
Staffing With COVID-19 Cases,'' JAMA Network (Aug. 10, 2020), https://
jamanetwork.com/journals/jama/fullarticle/
2769437?guestAccessKey=258f9d19-b7c2-43e2-9218
-
55c23d3914bc&utm_source=silverchair&utm_medium=email&utm_campaign=articl
e_alert-jama
&utm_content=olf&utm_term=081020.
\5\ Yue Li, H. Temkin-Greener, S. Gao, X. Cai, ``COVID-19
infections and deaths among Connecticut nursing home residents:
facility correlates,'' Journal of American Geriatrics Society (2020),
https://onlinelibrary.wiley.com/doi/epdf/10.1111/jgs.16689.
In January 2021, the New York State Attorney General found ``Staffing
was more determinative of death rates than `COVID-19 geography' during
the initial wave of the pandemic.''\6\ Attorney General James found
that although the harshest impact of COVID-19 was in New York City and
neighboring counties at the beginning of the pandemic, the death rate
was half in facilities in this geographic area that had the highest (5-
star) ratings in staffing.
---------------------------------------------------------------------------
\6\ New York State Office of the Attorney General Letitia James,
Nursing Home Response to COVID-19 Pandemic, p. 30 (revised Jan. 30,
2021), https://ag.ny.gov/sites/default/files/2021-
nursinghomesreport.pdf.
The direct care workforce also needs to be strengthened. The
paraprofessional workers who provide most of the hands-on care for
residents need a living wage \7\ and comprehensive benefits, including
paid sick leave.\8\ Over the past year, the virus has been spread to
residents and staff by infected but asymptomatic workers who work in
multiple facilities, often because they earn such low wages, minimum
wage or just above minimum wage, that they need multiple jobs to try to
make ends meet and pay their bills. Direct care workers frequently lack
health insurance and paid sick leave, leading them to work when
sick.\9\
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\7\ LeadingAge recently released a report finding that paying a
living wage to the direct care workforce could pay for itself, just by
improving care for residents. Making Care Work Pay: How Paying at Least
a Living Wage to Direct Care Workers Could Benefit Care Recipients,
Workers, and Communities, https://leadingage.org/sites/default/files/
Making%20Care%20Work%20Pay
%20Report.pdf?_ga=2.118488393.1154178586.1601481977-
1021098696.1598989890.
\8\ PHI, Caring for the Future: The Power and Potential of
America's Direct Care Workforce (Jan. 12, 2021), reached through a link
at Caring for the Future: The Power and Potential of America's Direct
Care Workforce--PHI (phinational.org).
\9\ Harold Van Houtven, Nicole DePasquale, Norma B. Coe,
``Essential Long-Term Care Workers Commonly Hold Second Jobs and
Double- or Triple-Duty Caregiving Roles,'' Journal of the American
Geriatrics Society, Vol. 68, Issue 8, pp. 1657-1660 (published Apr. 27,
2020), https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/
jgs.16509.
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2. Poor infection control practices
In May 2020, the Government Accountability Office (GAO) reported that
infection control was the most frequently cited deficiency in nursing
homes in the pre-
pandemic period 2013-2017, with 40 percent of facilities cited each
year and 82 percent cited at least once in the 5-year period.\10\ The
guidance for COVID-19 is no different from the guidance for all
infections: staff must wash their hands, properly disinfect medical
equipment between residents, properly and consistently use personal
protective equipment, and identify, track, and isolate residents who
appear to have, or who are confirmed to have, infectious diseases.
---------------------------------------------------------------------------
\10\ ``Infection Control Deficiencies Were Widespread and
Persistent in Nursing Homes Prior to COVID-19 Pandemic,'' GAO-20-576R,
p. 4 (May 20, 2020), https://www.gao.gov/products/GAO-20-576R.
---------------------------------------------------------------------------
3. Limited enforcement of standards of care
The GAO reports that only one percent of facilities cited with an
infection control deficiency between 2013 and 2017 received any kind of
financial penalty.\11\ Facilities ignore deficiencies when they know
deficiencies are unlikely to be cited and, if cited, unlikely to lead
to any consequence.
---------------------------------------------------------------------------
\11\ Id.
The Trump Administration dramatically rolled back the already-weak
federal enforcement system, largely through sub-regulatory guidance
documents (survey and certification letters addressed to state survey
agencies).\12\ The result of the changes has been few and comparatively
small per instance financial penalties (rather than per day penalties
that the Obama Administration mandated as the default type of civil
money penalty). The few reported decisions by Administrative Law Judges
that have been issued since the Trump Administration decimated the
enforcement system suggest that no financial penalties were imposed for
facilities' noncompliance or that penalties were so low that facilities
chose not to appeal or both.
---------------------------------------------------------------------------
\12\ See Jordan Rau, ``Trump Administration Eases Nursing Home
Fines in Victory for Industry,'' The New York Times (Dec. 24, 2017),
https://www.nytimes.com/2017/12/24/business/trump-administration-
nursing-home-penalties.html?searchResultPosition=2; Toby S. Edelman,
``Deregulating Nursing Homes,'' Bifocal, Vol. 39, No. 3, p. 31 (Jan.-
Feb. 2018), final-bifocal_39_3.pdf (americanbar.org); testimony of Toby
S. Edelman at Hearing before House Ways and Means Committee,
Subcommittee on Health, ``Examining the COVID-19 Nursing Home Crisis
(Jun. 25, 2020), https://waysandmeans.house.gov/sites/
democrats.waysandmeans.house.
gov/files/documents/Toby%20Edelman_Testimony.pdf.
---------------------------------------------------------------------------
Solutions
1. Require meaningful nurse staffing levels and reverse the
dismantling of the enforcement system
The Senate Finance Committee must require meaningful nurse staffing
ratios at all levels and require improved salaries, benefits, and
working conditions for the paraprofessional workforce. The Committee
further needs to call on the Centers for Medicare and Medicaid Services
to reverse the dismantling of the enforcement system so that meaningful
and appropriate sanctions are promptly imposed for noncompliance with
federal standards of care.
In addition, the Committee needs to address changes in the nursing home
industry since the 1987 Nursing Home Reform Law was enacted that have
reduced accountability for the quality of care that facilities provide
and for public spending.
2. Enact laws to prohibit or at least restrict/reduce provider
self-dealing
Jordan Rau of Kaiser Health News reported in The New York Times 3 years
ago that nearly three-quarters of all nursing facilities in the country
buy goods and services, such as therapy services, management services,
medications, and rent, often at inflated prices, from companies that
they own and control.\13\ The result of these related-party
transactions is that facilities are able to hide profits as the cost of
doing business. In 2015, facilities' contracts with related parties
accounted for $11 billion, a tenth of facilities' Medicare
reimbursement. Rau described two New York owners whose family trusts
took $40 million of the $145 million that their facilities received as
reimbursement over an 8-year period--a 28 percent profit margin. Rau
reported Kaiser Health News's analysis that found facilities engaging
in these practices have fewer nurses and aides to provide care to
residents, ``higher rates of patient injuries and unsafe practices,''
and twice as many complaints as other facilities.
---------------------------------------------------------------------------
\13\ Jordan Rau, ``Care Suffers as More Nursing Homes Feed Money
Into Corporate Webs,'' The New York Times (Jan. 2, 2018), https://
www.nytimes.com/2018/01/02/business/nursing-homes-care-
corporate.html?searchResultPosition=9.
In December 2020, Debbie Cenziper and colleagues at The Washington Post
documented the self-dealing of California's largest nursing home
operator, Brius Healthcare Services, whose nursing facilities paid $103
million to related companies in 2018 for supplies, administrative
services and financial consulting, and rent, among other services.\14\
Care at many Brius facilities was so poor that, in 2014, then-
California Attorney General Kamala Harris took an unprecedented step of
filing an emergency motion in bankruptcy court in an effort to prevent
the court from giving Brius additional facilities. Harris's motion
called the company a ``serial violator of rules within the skilled
nursing industry.''
---------------------------------------------------------------------------
\14\ Debbie Cenziper, ``Profit and pain: How California's largest
nursing home chain amassed millions as scrutiny mounted,'' Washington
Post (Dec. 31, 2020), https://www.washingtonpost.
com/business/2020/12/31/brius-nursing-home.
The Naples Daily News reported in 2018 that Consulate Health Care, the
largest nursing home operator in Florida and sixth largest operator in
the country (with 210 facilities and 22,059 beds in 21 states), founded
in 2006 and owned by the
Atlanta-based private equity firm Formation Capital, designed its
facilities ``to appear cash-strapped.''\15\ The article described the
chain's individual facilities as ``essentially empty shells, they pay
rent, management and rehabilitation service fees to Consulate or
Formation Capital-affiliated companies.'' One Consulate facility paid
$467,022 in management fees and $294,564 in rent to two companies owned
by Consulate and Formation Capital. Forty-eight of Consulate's 77
Florida nursing facilities had one or two stars, the lowest ratings, on
the federal website, then called Nursing Home Compare. In ``an
unprecedented action'' in January 2018, the state threatened to close
53 of the corporation's 77 Florida facilities under a state law that
authorizes revocation of state licenses for serious violations at
facilities under common ownership.\16\
---------------------------------------------------------------------------
\15\ Ryan Mills and Melanie Payne, ``Neglected: Florida's largest
nursing home owner represents trend toward corporate control,'' Naples
Daily News (May 31, 2018), https://www.
naplesnews.com/story/news/special-reports/2018/05/31/floridas-largest-
nursing-home-owner-part-growing-national-trend/581511002/.
\16\ Ryan Mills and Melanie Payne, ``Neglected: Florida's largest
nursing home chain survives despite legacy of poor patient care,''
Naples Daily News (May 31, 2018), https://www.
naplesnews.com/story/news/special-reports/2018/05/31/neglected-fraud-
and-abuse-nursing-homes-florida/542609002/.
3. Enact laws (with enforceable consequences for violations)
limiting the amount of public reimbursement that can be spent on
---------------------------------------------------------------------------
profits, administration, and overhead
A financial issue related to self-dealing is the need for new federal
and state rules to require facilities to spend designated portions of
their reimbursement on care of residents and to set, and enforce,
strict limits on how much can be spent on administrative costs,
management fees, and profits. Congress enacted such rules, called
medical loss ratios, in the Affordable Care Act for Medicare managed
care plans. The state of New Jersey recently enacted legislation for
nursing facilities to mandate direct care ratios, which limit the
percentage of reimbursement that can be spent on administrative costs
and profits.\17\
---------------------------------------------------------------------------
\17\ A4482/S2758, https://www.njleg.state.nj.us/2020/Bills/A4500/
4482_R2.PDF; ``Governor Murphy Signs Legislative Package to Strengthen
the Resiliency and Preparedness of New Jersey's Long-Term Care
Industry'' (News Release, Sep. 16, 2020), https://www.nj.gov/governor/
news/news/562020/approved/20200916b.shtml.
Congress should enact direct care ratio requirements for the Medicare
---------------------------------------------------------------------------
and Medicaid reimbursement that facilities receive.
4. Enact laws (with enforceable consequences for violations)
identifying who is eligible to own and manage nursing facilities
Nursing facilities are bought and sold and management contracts are
signed with virtually no oversight and few limits set by states.
Increasingly, multiple limited liability companies take pieces of a
nursing home business. With multiple companies, it is difficult, and
intentionally so,\18\ for government and private parties to hold
facilities accountable for poor care.
---------------------------------------------------------------------------
\18\ Joseph E. Casson and Julia McMillen, ``Protecting Nursing Home
Companies: Limiting Liability Through Corporate Restructuring,''
Journal of Health Law, Fall 2003, Vol. 36, No. 4.
Secrecy surrounds changes of ownership and management. The example of
Skyline Healthcare is illustrative. Beginning in late 2015, the New
Jersey-based Skyline Healthcare took over management of more than 100
facilities across the country in little more than year. Almost as
quickly as it acquired facilities, Skyline began to default, failing to
pay vendors and staff. States across the country went to court to get
receiverships in order to be able to pay vendors and staff and provide
residents with food and medications.\19\ Information about new owners
was often kept secret. On April 27, 2018, for example, Pennsylvania
installed a temporary manager at nine facilities operated by Skyline,
but the state declined to identify the manager.\20\ As reported on May
5, Pennsylvania identified as the new operator of the Skyline facility
in Lancaster a new for-profit company that had been created just three
days earlier, on May 2. The so-called new operator was not actually
new. It had at least two of the same owners and shared the address of a
company, Priority Healthcare Group, that had actually bought 14
facilities in the state in 2016.\21\ Priority's record managing 11
former Golden Living facilities in Pennsylvania was poor. Priority cut
staffing levels and reduced other spending at the facilities.\22\ Yet
this is the so-called new company that Pennsylvania entrusted with a
former Skyline facility.
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\19\ Laura Strickler, Stephanie Gosk, Shelby Hanssen, ``A nursing
home chain grows too fast and collapses, and elderly and disabled
residents pay the price,'' NBC News (Jul. 19, 2019), https://
www.nbcnews.com/health/aging/nursing-home-chain-grows-too-fast-
collapses-elderly-disabled-residents-n1025381.
\20\ Harold Brubaker, ``Pa. ousts Skyline Healthcare from nine Pa.
nursing homes,'' Philadelphia Inquirer (May 2, 2018), Pa. ousts Skyline
Healthcare from nine Pa. nursing homes (inquirer.com).
\21\ Heather Stauffer, ``Lancaster nursing home formerly run by
Skyline has a new operator,'' Lancasteronline (May 26, 2018), https://
lancasteronline.com/news/local/lancaster-nursing-home-formerly-run-by-
skyline-has-a-new/article_7df1ad0a-6057-11e8-937b-3393e543dbb7.html.
\22\ Daniel Simmons-Ritchie, ``Worst nursing homes continue to fail
the frail despite lawsuit and promises; Golden Living's homes changed
hands, but the care never got better,'' PennLive (Nov. 26, 2018),
https://www.witf.org/2018/11/26/worst-nursing-homes-continue-to-fail-
the-frail-despite-lawsuit-and-promises/.
State licensure rules governing ownership and management are openly
flouted. For example, New York purchasers of five nursing facilities in
Vermont began operating the facilities in October 2020,\23\ before
going through a new state review process for nursing home sales that
requires consideration of past records at other facilities.\24\ The New
Yorkers' record includes Priority Healthcare Group, whose Pennsylvania
facilities were cited with low staffing levels and poor quality
care.\25\
---------------------------------------------------------------------------
\23\ Katie Jickling, ``Three New York-based owners take over
management of five Genesis nursing homes,'' Vtdigger (Nov. 13, 2020),
https://vtdigger.org/2020/11/13/three-new-york-based-owners-takes-over-
management-of-five-genesis-nursing-homes/.
\24\ Bill No. 125, 2018, establishing Nursing Home Oversight
Working Group and (section 3) an Interim Review Process for Transfer of
Nursing Home Ownership (effective July 1, 2018), https://
legislature.vermont.gov/Documents/2018/Docs/ACTS/ACT125/
ACT125%20As%20En
acted.pdf; signed by Governor May 10, 2018, hj180510.pdf (vermont.gov).
\25\ Daniel Simmons-Ritchie, ``Worst nursing homes continue to fail
the frail despite lawsuit and promises; Golden Living's homes changed
hands, but the care never got better,'' PennLive (Nov. 26, 2018),
https://www.witf.org/2018/11/26/worst-nursing-homes-continue-to-fail-
the-frail-despite-lawsuit-and-promises/.
The federal government appears to believe that any facility with a
state license is eligible for Medicare and Medicaid certification, no
questions asked. The abandonment of state or federal responsibility and
actions to ensure that only qualified owners and managers own and
operate nursing facilities has led to the growing concentration of
nursing facilities in private equity firms, real estate investment
trusts, and other private owners that have little apparent knowledge
about or interest in providing high quality care, to the detriment of
residents and staff. This issue is not new but has only gotten worse
---------------------------------------------------------------------------
over time.
More than 25 years ago, in 1994, Jon Robertson formed Phoenix Health
Group and acquired nursing facilities in California. The Los Angeles
Times reported in 1997, ``As the money began to roll in from Medicare
and Medi-Cal payments to the more than 300 residents at the facilities,
Robertson, who had long displayed a fondness for life's pricier
pleasures--from Harley-Davidson motorcycles to diamond rings--began to
spend conspicuously.''\26\ In 1996, Robertson checked into a
rehabilitation center in Phoenix to deal with a cocaine addiction.
Robertson also ``served prison time and owed $150,000 in restitution to
the IRS for filing a false tax return as president of another nursing
home management company.''\27\ Robertson's California facilities
provided poor care for residents and were cited with numerous
deficiencies. The company filed for bankruptcy and abruptly closed its
facilities.
---------------------------------------------------------------------------
\26\ Eric Slater, ``Entrepreneur Fades From View as Empire
Collapses,'' Los Angeles Times (Oct. 23, 1997), https://
www.latimes.com/archives/la-xpm-1997-oct-23-mn-45876-story.html.
\27\ The Associated Press, ``Utah company facing bankruptcy;
nursing home residents in limbo,'' The Salt Lake Tribune (May 13,
2015).
Despite this record and sometime after his drug rehabilitation and
prison sentence, Robertson formed a new company, Utah-based Deseret
Health Group. Multiple states gave licenses to facilities owned by
Robertson's new company and the federal government certified the
facilities for Medicare and Medicaid reimbursement. In early May 2015,
Robertson repeated his pattern from California. Deseret abruptly
stopped paying for food, medical supplies, and workers' wages and
benefits in nursing facilities owned by the company in Kansas,
Minnesota, Nebraska, and Wyoming. States pursued court receiverships or
otherwise took control of the facilities to protect residents and
ensure they received food and medications.\28\
---------------------------------------------------------------------------
\28\ See, e.g., H.B. Lawson, ``Nursing home faces closure,'' The
Saratoga Sun (May 6, 2015), https://www.saratogasun.com/story/2015/05/
06/news/nursing-home-faces-closure/3898.html.
Private equity ownership of nursing homes has created special problems.
In 2007, The New York Times reported ``more profit and less nursing''
in facilities owned by private equity firms.\29\
---------------------------------------------------------------------------
\29\ Charles Duhigg, ``At Many Nursing Homes, More Profit and Less
Nursing,'' The New York Times (Sep. 23, 2007), https://www.nytimes.com/
2007/09/23/business/23nursing.html.
A research study looking at nursing home ownership between 2000 and
2017 found that private equity (PE) ownership increased the probability
of death during a resident's stay by 1.7 percentage points (meaning
that ``about 20,150 Medicare lives [were] lost due to PE ownership'')
while Medicare costs for residents' care increased by 11 percent.\30\
Facilities owned by private equity firms reduced staffing and
increased, by 50 percent, the use of antipsychotic drugs.
---------------------------------------------------------------------------
\30\ Atul Gupta, Sabrina T. Howell, Constantine Yannelis, and
Abhinav Gupta, ``Does Private Equity Investment in Healthcare Benefit
Patients? Evidence from Nursing Homes,'' Becker Friedman Institute,
Working Paper No. 2021-20 (Feb. 2021), https://bfi.uchicago.edu/wp-
content/uploads/2021/02/BFI_WP_2021-20.pdf.
During the coronavirus pandemic, The Washington Post reported that
Portopiccolo Group, a private equity firm with a record of poor care
(nearly 70 percent of Portopiccolo facilities have ratings of one or
two (of five) on the federal website), short staffing, and coronavirus
outbreaks, bought at least 22 nursing facilities, with ``scant
scrutiny'' from state regulators in Maryland and Virginia.\31\ As in
the facilities it already owned, Portopiccolo reduced operating
expenses (reducing cleaning supplies and personal protective equipment)
and reduced workers' benefits. The results were poorer care for
residents.
---------------------------------------------------------------------------
\31\ Rebecca Tan and Rachel Chason, ``An investment firm snapped up
nursing homes during the pandemic. Employees say care suffered,'' The
Washington Post (Dec. 21, 2020), https://www.washingtonpost.com/local/
portopiccolo-nursing-homes-maryland/2020/12/21/a1ffb2a6-292b-11eb-9b14-
ad872157ebc9_story.html.
A February 2021 posting in Health Affairs made these points in a
---------------------------------------------------------------------------
scathing indictment of the nursing home industry:
Prior to the pandemic, persistent problems with nursing home
care had been documented for years, often because of too few
and inadequately trained frontline staff. The harm to frail
older adults can be quite severe--abuse and sexual assault,
infections, overuse of psychotropic medications, pressure
ulcers, falls with injuries, weight loss, dehydration, pain,
and medication errors. Infection control violations have also
been found repeatedly in a majority of nursing homes.
Quality issues persist as policy makers are unable to oversee
how nursing homes spend Medicare and Medicaid payments. The
growth in complex nursing-home ownership structures has limited
financial transparency by allowing nursing homes to hide public
payments and stint on direct resident care. We recommend
specific policy changes to make ownership, management, and
financing more transparent and accountable to improve U.S.
nursing home care.\32\
---------------------------------------------------------------------------
\32\ Charlene Harrington, Anne Montgomery, Terris King, David C.
Grabowski, Michael Wasserman, ``These Administrative Actions Would
Improve Nursing Home Ownership and Financial Transparency in the Post
COVID-19 Period,'' Health Affairs (Feb. 11, 2021), https://
www.healthaffairs.org/do/10.1377/hblog20210208.597573/full/.
The Committee should address the issue of nursing home ownership and
management and enact, with appropriate enforcement mechanisms,
meaningful statutory standards for state licensure and federal
certification.
Conclusion
Staffing is the critical factor that makes good care possible. Unless
facilities have sufficient professional and paraprofessional staff and
treat all staff well, care will not improve. Improving staffing is
absolutely necessary, but it is not sufficient.
In addition, states and the federal government need to limit licensure
and certification, respectively, to owners and managers that are
knowledgeable about and demonstrate commitment and the financial
capacity to provide high quality care to residents. Finally, public
reimbursement must be spent on care for residents and not diverted to
management fees, overhead, and excessive profits.
Many of these issues have been raised before.\33\ The Committee now has
the opportunity to dramatically improve care for residents and working
conditions for workers by addressing these issues.
---------------------------------------------------------------------------
\33\ ``Buying and Selling Nursing Homes: Who's Looking Out for the
Residents?'' (CMA Alert, May 23, 2018), https://medicareadvocacy.org/
buying-and-selling-nursing-homes-whos-looking-out-for-the-residents/.
______
Statement Submitted by Elizabeth Hamilton
Thank you, Chairman Wyden, Ranking Member Crapo, and members of the
Senate Finance Committee, for allowing additional statements to this
hearing. My name is Elizabeth Hamilton. My mother is 96 years old and
currently is a resident in a memory care unit in Seattle, Washington.
On March 10, 2021 The Center for Medicaid and Medicare Services (CMS)
released updated and expanded guidelines for inside and in person
visitation in Nursing Homes. Unfortunately the facility my mother is in
has not updated their restrictions to comply with these new guidelines
stating they are following state guidelines. The Governor as of this
writing has not released any changes to the current restrictions now in
place.
Residents of long-term care (LTC) have been languishing in facilities
across the nation, in varying degrees of ``lockdown'' since March 13,
2020. Initially, scores succumbed to a deadly virus we knew little
about. Facilities were not prepared; none of us were. Much has changed
in a year. It's time for CMS to reinforce adherence to existing
guidelines for compassionate care visits, essential caregiver
designation, and infection control, and to update its guidance for the
safe and strategic reopening of facilities.
LTC facilities now have the capacity to follow proven protocols--
masking, social distancing, disinfection, selectively restricted
movement. Testing is widely available. Infection and death rates in
long-term care have dropped dramatically. Many staff, residents and
family members have been (or soon will be) injected and protected with
incredibly effective vaccines, far more than they typically are from
seasonal flu. A year ago we talked about ``protecting the most
vulnerable.'' With proven safety precautions in place, testing
available, and vaccinations given, a year later we are ``protecting
them to death.'' At the same time, guidelines allowing for
compassionate care visits and essential caregiver designation are being
completely ignored by many facilities, and proper infection control is
not happening everywhere. You can help eliminate these disparities.
Families have been patient, hunkering down outdoors, even in frigid
temperatures, to connect with their loved ones. LTC residents are
depressed and despondent, as are staff members. Our loved ones are
suffering from increased falls and troubling weight loss. Many have
gone nearly a year without a haircut or a thorough teeth cleaning. Some
have given up and died quietly, either with no family present or with
the requisite one or two family members at their bedsides. The negative
physical and emotional toll of these policies on our families far
outweighs any benefit.
Some facilities in the nation have begun to open up. But with
guidelines from last fall still in place, regardless of vaccine status
among residents, an entire facility is still on lockdown for a singular
asymptomatic case. This makes no sense. The injury to our loved ones
and our families goes on and on.
We need swift delivery of updated, common sense guidelines to safely
and strategically open up facilities, balancing vastly decreased risk
from the virus with quality of life. You have the ability to end the
isolation that has devastated lives in long-term care and reunite our
families. We have all suffered long enough. It is time.
______
Statement Submitted by Tamra Holland
Members of the Senate Finance Committee, thank you for choosing to make
the tragedies that occurred residential facilities throughout the
United States over the past 13 months a focus of your attention. I
write to you as one of thousands of family members painfully familiar
with an aspect of this story not well understood by the majority of
Americans.
My mother Darlene entered a facility on March 18, 2020 for
rehabilitation following a stroke the month before. She had made good
physical progress in an acute hospital rehabilitation but needed
additional time of daily professional therapies. During the hospital
rehabilitation prior the lockdown, family was present with her every
day for therapy homework, helping with her personal care and emotional
well-being. We knew once transferred to the long-term care rehab
facility we would not be able to immediately visit but had faith her
care needs would be meet and we would be involved in some manner.
My mother-in-law Joan was also a long-term resident of this facility in
the skilled nursing wing. My husband and I visited her regularly and
were comfortable with her care.
Having many family members on the front lines of healthcare and a long
career in pharmacy myself, I understood the need for a lockdown in
March of 2020. The pandemic was a roaring freight train and even the
best of facilities needed that sudden stop in visitation. There was not
enough known about the virus, there was not enough PPE, residential
facilities did not have the infection control policies that the
pandemic required. They were not prepared, none of us were.
Having to say goodbye to my Mother as the facility van picked her up at
the hospital was heartbreaking. However, at that point I still expected
the facility care would be appropriate and she would get the
rehabilitation therapy she needed to return to independently living in
her apartment. What I found was a facility that suddenly had an
overwhelmed phone system and no communication plan for families. I
could see through my Mom's window that she was still in bed at noon
each day. None of her personal belongings were unpacked or put away.
She experienced a fall within the first 48 hours of being in the
facility. Mom was confused with the change in environment and no one
there to help her acclimate. The staff were used to family helping
settle in new residents and personalizing the sterile environment of
the room. Staff did not seem aware there was a gap in care because
family was not inside the building.
In these early days I expected communication was key to Mom's quality
of care and rehabilitation as well as the continued good care of my
Mother-in-law Joan. Phone contact was difficult because you could not
call directly to the nursing unit to speak to staff. A central operator
had difficulty suddenly fielding all communication coming in. Calls
then transferred to the nursing unit frequently were never answered.
Imagine the anxiety of trying to speak to staff about a loved one's
care and listening to the phone ring and ring. This lack of contact,
the lack of any direct information lead to an assumption of lack of
care. When your mind does not have valid information to deal with it
imagines something that can be vastly different than the reality. This
was the situation for months as no visiting was allowed. I tried email
with the facility director which went unanswered. I left voicemails and
phone messages. I left things at the front door for both Darlene and
Joan hoping they would know that we still cared about them. Darlene had
a cellphone and we sometimes were able to speak to her. However, often
the phone was not answered because she could not hear it, could not
find it or it wasn't charged. Asking staff to help her with the phone
required the same phone contact that I described above. Joan was not
able to hold a phone and requesting staff help her was often met with
exasperation. I established contact with the facility corporate
leadership. At first this seemed it would be productive. I asked for
some avenues of communication, establishment of a family council,
family newsletter, holiday decorating by family (outside). I offered to
help in any or all of these ideas. After a few promises of action by
the COO that were left unfulfilled all communications ceased.
I applied for job openings at the facility. I am a pharmacist and have
during my career done medication record reviews in skilled nursing
facilities. I learned that this required monthly reviewed of each
patient's record had been suspended at the beginning of the lockdown.
The process had gone virtual but with much of the record only on paper
a full review was impossible. I applied to work in the kitchen only to
be told by human resources even if I was allowed the job, I would be
assigned a hallway away from whatever one Darlene or Joan was on. It
was a comment rooted in sear meanness. I continued to apply for an
ongoing job opening in the food service for months. I never got a
response from anyone at the facility about it.
Darlene had some health needs that required physician visits. Each of
these were a struggle to schedule. Even when the facility had no cases
of COVID, Darlene's right to medical care was questioned at every turn.
As the months of the lockdown continued this only grew more difficult.
At a time when a single positive case in a separate hallway from
Darlene's, and she herself had tested negative, the facility canceled a
medically necessary appointment. They did this prior to even discussing
it with me her POA. I was livid. I knew how essential this appointment
was. I knew the ADON was wrong to deny it and it was not only within
Darlene's rights to go but also critical to her health. I pleaded, I
argued, I insisted, I requested help from the state ombudsman. My
efforts were responded to by a threat of expelling Darlene from the
facility by the ADON. That medical appointment was never allowed.
During these months we did window visits. We celebrated Darlene and
Joan's birthdays with a window party. We used the iPad. We did outside
visits when neither of them could hear us well and a monitor from the
facility sat nearby and eased dropped on every word said. We smiled
while there and cried all the way home. Wanting only to offer some
happiness, some hope, some dignity to these two women that meant so
much to us.
In November Darlene suffered a stroke. Although it was a known medical
risk for her, I am certain it was brought on by the isolation and lack
of hope. Studies have shown that stroke risk is increased by 32% due to
isolation. While in the hospital emergency department I was able to be
with her. We spent 26 hours holding hands. The facility assured me that
she had just gotten a negative COVID test result. Within hours of her
admission to the floor a COVID test was performed due to a slight
fever, it was positive. With her physical health compromised by the
stroke, she could not overcome the virus. She passed away on November
20, 2020. The last 8 months of her life were the saddest of her 82
years.
Joan also contracted COVID at the facility. Although no family were
allowed access, staff of course came and went in their daily lives. One
after another they tested positive and passed the virus to residents.
Joan endured 2 exceptionally lonely weeks in isolation and seemed
recovered. Within weeks staff began reporting Joan was not eating and
was increasingly weak. The family had end of life discussions. We did
not expect her to see the New Year. My husband and his sister applied
for compassionate care. It was allowed. As family helped Joan eat meals
each day her condition improved. Now 3 months later it is clear that
her declining health in December was in large part malnutrition.
Residents were required to eat in their rooms alone. Staff would set a
tray in front of her which she could not functionally manage.
Certainly, she has a small appetite at 89 years of age, but her primary
reason for not eating was that she could not do it independently. There
is not enough staff to feed residents in their rooms one at a time.
This Is such a clear example of why family is essential to the health
of loved ones in facilities.
There must be changes in the system. There are vast opportunities for
learning from this pandemic. Please do not let stories like Darlene and
Joan's be wasted by inaction. Long-term residential facilities for the
elderly and the developmentally disabled of any age, need to be
reformed. After over 30 years in acute healthcare, I know that
caregivers at every level want to provide quality care to patients.
Physicians, nurses, PA, CNA among others all have a role in each
patient's care. They each deserve a workplace that recognizes the value
they bring, provides them with a safe workplace and has policies and
procedure that allow them to do a quality job. They need to be listened
to. They need to be part of the change that is needed.
Families as well need to be involved. They are essential. Communication
is such an undervalued tool to improvement. Family councils should be
in every facility. Quarterly care plans may be sufficient in normal
times when families are seeing their loved ones regularly. However,
during the lockdown families should have heard from a caregiver weekly
or more. I know hospitals that had nurses call families for updates
daily. I find no excuses for the unanswered emails I sent to facility
administrators. A busy schedule is no rationalization for months of
time without response under the circumstances of the pandemic.
Facilities need to adopt principles that have guided acute healthcare
institutions. Quality improvement, staff development, patient centered
care principles long held by hospital systems need to be adapted by
long-term care corporations. Residents and family that entrust them for
care deserve no less.
Residential facilities will always be needed. Medical care cannot
always be provided within the home. Families may not have the physical,
emotional or financial means to care for loved ones at home. However,
experiences and memories of the lockdown threaten the future of these
facilities. People are renovating their homes, changing life decisions
about care in their later years. Many facilities managed by big
corporation are going to have to rethink their priorities to appeal to
many again. This is the perfect time for change, real meaningful change
that is good for residents, families and facilities.
Thank you all for your attention to the unfortunate effects the
lockdown has had on residents and families. Please do let Darlene and
Joan's stories be forgotten. Allow the lessons learned to lead to
better care. Quality care that this vulnerable population deserves.
______
Statement Submitted by Gay L. Hull
Hi, my name is Gay Hull and my daughter Mandy Hull resides at Shapiro
Developmental Center in Kankakee, IL. Mandy's service providers have
shown us throughout the pandemic that they truly care about our
daughter, but her Shapiro family cannot replace the love, affection,
and enrichment that we provide towards her quality of life.
We have always been very involved parents. Prior to COVID we would
travel 2\1/2\ hours, every other weekend, to spend the afternoon with
Mandy. During these visits we would take her out to eat, shopping at
the Mall or Wal-Mart or for long walks at local parks. We have always
had her home during all holidays so she could spend time with her
brother and sister and we have never missed a birthday celebration. We
love the time that we spend with all of our children, but we especially
cherish our time with Mandy.
Since COVID started in March of 2020, we were prohibited from visiting
Mandy on many, many occasions. Mandy has not done well with these
restrictions. This past year has been heartbreaking for all of us. She
has been quarantined off and on to her room or the building. She has
also not been able to leave her room, go outside to walk or to get some
fresh air, spend time with her family, enjoy a variety of daily
activities such as campus vocational training, or have access to her
favorite foods and snacks. Her behavior has worsened because of these
unreasonable restrictions. We feel that these restrictions have been
cruel, inhumane, and discriminatory!
Over the past year, we have tried to do everything possible to let her
know that we have not deserted or abandoned her . . . that we were
still in her world, but Face Timing, phone calls, and mailed care
packages, could not possibly replace the physical presence of her
parents. Fortunately, we have been granted Compassionate Caregiver
designation, thanks to the Illinois Caregivers 4 Compromise and Mandy
is able to see us weekly, but she has NO other freedoms.
As her parents, we want safe, reasonable practices. The isolation must
stop! Can you please help us? Thank you.
______
Letter Submitted by Kathy James
Dear Senators,
A year ago I spent a quiet afternoon with my then 89 year old mother in
her assisted living facility. We watched Jeopardy together and then the
4:00 news. At 5:00 I wheeled her down to dinner, hugged her goodbye,
said see you tomorrow and that was the last time I would touch her even
until today. Each day, I go to her window at the facility and call her
on her phone to stand and talk to her. I want her to have my presence
near so she does not feel alone. She had only been a widow for one year
at the start of the pandemic after being married for 69 years. The
loneliness is extreme. It is also difficult for her to get around as
she is crippled from arthritis. She has had to manage without the help
I would give her in keeping her room clean, watering her plants,
putting things away. The staff can only help so much. So all the little
things that family can do to help fall by the wayside. I was able to
see her at a half hour visit last week and I can see her fatigue after
just ten minutes of talking. Because she hasn't talked to anyone for
that long in over a year. I would ask that you would take very
seriously passing legislation so this complete lockout of families
never has to happen again. A time limit should be allowed to get
protocols in place and then facilities need to open to families. We
fight not just for them but for my future and yours. I know I would not
be able to handle what she has gone through. And many, many did not.
They are no longer here to tell their stories.
Sincerely,
Kathy James
______
Justice in Aging
1444 Eye Street, NW, Suite 1100
Washington, DC 20005
202-289-6976
https://justiceinaging.org/
Justice in Aging appreciates the opportunity to submit a written
statement for the record. Justice in Aging is an advocacy organization
with the mission of improving the lives of low-income older adults. We
use the power of law to fight senior poverty by securing access to
affordable health care, economic security, and the courts for older
adults with limited resources. We have decades of experience with
nursing homes and other forms of long-term services and supports, with
a focus on the needs of low-income enrollees and populations that have
been marginalized and excluded from justice such as women, people of
color, people with disabilities, LGBTQ individuals, and people with
limited English proficiency.
Focus of this Statement: Breaking Through the Persistent Public Policy
Impasse.
In the past month, Congress has convened two hearings addressing the
need for nursing home reform: the Senate Finance Committee hearing
(March 17th), and a hearing on Examining Private Equity's Expanded Role
in the U.S. Health Care System, convened by the Oversight Subcommittee
of the House Ways and Means Committee (March 25). These hearings have
highlighted the persistently poor care provided to this country's
nursing home residents. Unfortunately, these problems are anything but
new.
As testimony in the Finance Committee hearing demonstrated, the COVID-
19 pandemic has exacerbated preexisting problems within nursing homes,
including, but not limited to, inadequate staffing and slipshod
infection prevention and control practices. The results have been
horrific, with approximately 175,000 deaths among residents and staff
of long-term care facilities,\1\ along with residents being isolated
from family members and friends for an entire year.
---------------------------------------------------------------------------
\1\ The COVID Tracking Project, The Long-Term Care COVID Tracker
(reviewed March 31, 2021), https://covidtracking.com/nursing-homes-
long-term-care-facilities.
Many observers have suggested that now, finally, is the time for
reforming our nursing home system. But reform is far from assured.
Change will require that Congress break through the gridlock that has
---------------------------------------------------------------------------
stymied nursing home public policy for several decades.
To a great extent, the public policy impasse on nursing home reform
stems from one central dynamic: providers claim that improvement is
impossible, due to allegedly insufficient Medicaid rates. Although they
may concede (for example) that facility staffing levels are too low,
they resist efforts to establish national staffing minimums, based
largely on arguments that Medicaid rates do not support adequate
staffing levels. As a result, nursing homes continue to staff at
dangerously low levels, which in turn leads to resident injuries and
death--before, during and after the pandemic.
In an effort to contribute to public policy solutions, this statement
focuses on one important aspect of the current problem: service
providers both a) claiming that Medicaid rates are inadequate while b)
organizing their finances in such a way that makes it virtually
impossible to determine appropriate rates. These counterproductive
practices are part of the dynamic that has made nursing home reform an
oxymoron for many years.
Nursing Home Residents Suffer Due to Inadequate Staffing Levels Linked
to Low Wages.
Short staffing is a longstanding problem in nursing homes. A recent
report found that 48.2% of direct-care workers earned less than a
living wage, with approximately 56% relying in part on public
assistance.\2\ Another study found nursing staff turnover rates of 94%
(mean) and 128% (median) over the course of a single year.\3\
---------------------------------------------------------------------------
\2\ Christian Weller et al., LeadingAge, Making Care Work Pay: How
Paying at Least a Living Wage to Direct Care Workers Could Benefit Care
Recipients, Workers, and Communities, at 8, 10 (2020) https://
leadingage.org/sites/default/files/Making%20Care%20Work%20Pay%20
Report.pdf.
\3\ Ashvin Gandhi et al., High Nursing Staff Turnover in Nursing
Homes Offers Important Quality Information, Health Affairs, vol. 40,
no. 3 (March 2021), https://www.healthaffairs.org/doi/10.1377/
hlthaff.2020.00957.
Not surprisingly, poor staffing has consequences. A study mandated by
the federal Nursing Home Reform Law determined appropriate staffing
levels based on facility quality measures, with the recommended levels
specific to nurse aides and nurses, and short-term and long-term
resident stays in the nursing home. That analysis found that 52 percent
of nursing homes failed to meet any of the recommended staffing levels,
while a full 97 percent of the nursing homes failed to meet at least
one of the recommended levels.\4\
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\4\ CMS, Appropriateness of Minimum Nurse Staffing Ratios in
Nursing Homes; Overview of the Phase II Report: Background, Study
Approach, Findings, and Conclusion, at 5 (2001) https://
www.justice.gov/sites/default/files/elderjustice/legacy/2015/07/12/
Appropriateness_of
_Minimum_Nurse_Staffing_Ratios_in_Nursing_Homes.pdf.
Numerous studies have confirmed this common-sense conclusion: low
staffing levels lead to poor resident care. Specific study results
include findings that low staffing levels are connected to avoidable
hospitalizations, more deficiencies, and poorer nurse aide
performance.\5\
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\5\ See, e.g., William Spector et al., Potentially Avoidable
Hospitalizations for Elderly Long-Stay Residents in Nursing Homes,
Medical Care, vol. 51, no. 8, at 673 (Aug. 2013) (low staffing linked
to avoidable hospitalizations), https://pubmed.ncbi.nlm.nih.gov/
23703648/; Nicholas Castle et al., Caregiver Staffing in Nursing Homes
and their Influence on Quality of Care: Using Dynamic Panel Estimation
Methods, Medical Care, vol. 49, no. 6, at 545 (June 2011) (better
staffing linked to better quality), https://pubmed.ncbi.nlm.nih.gov/
21577182/; Nicholas Castle et al., Nursing Home Deficiency Citations
for Safety, J. Aging and Social Policy, vol. 23, no. 1, at 34 (Jan.
2011) (low staffing correlated to deficiencies cited by survey agency),
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4878686/; John Schnelle et
al., Relationship of Nursing Home Staffing to Quality of Care?, Health
Serv. Res., vol. 39, no. 2, at 225 (April 2004) (higher staffing linked
to better performance by nurse aides), https://pubmed.ncbi.nlm.nih.gov/
15032952/.
In related findings, studies also have shown a relationship between
quality and the staffing levels for registered nurses. Current federal
law requires only that a nursing home employ a registered nurse for
eight hours daily.\6\ Studies have shown that higher staffing levels
for registered nurses lead to better care for residents.\7\
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\6\ 42 U.S.C. Sec. Sec. 1395i-3(b)(4)(C)(i), 1396r(b)(4)(C)(i); 42
CFR Sec. 483.35(b).
\7\ See, e.g., Mary Ellen Dellefield et al., The Relationship
Between Registered Nurses and Nursing Home Quality: An Integrative
Review (2008-2014), Nurs. Econ., vol. 33, no. 2, at 95 (March-April
2015) (literature review), https://pubmed.ncbi.nlm.nih.gov/26281280/.
Not surprisingly, the ongoing pandemic has only made adequate staffing
more consequential. Studies in both Connecticut and California found
that higher staffing of registered nurses allowed nursing homes to
better limit the spread of COVID-19.\8\ Also, these quality of care
problems have fallen particularly hard on persons of color. The
Connecticut study, for example, found greater COVID-19 spread among
nursing homes with higher percentages of residents of color.\9\
Furthermore, the same principal author studied nationwide data and
found that nursing homes with a greater percentages of residents of
color were more likely to suffer COVID-19 cases and deaths.\10\ The New
York Times reached similar conclusions, noting a ``striking racial
divide'' in how COVID-19 afflicted those nursing home with high
percentages of Black and Latino residents.\11\
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\8\ Yue Li et al., COVID-19 Infections and Deaths Among Connecticut
Nursing Home Resident: Facility Correlates, J. Am. Geriatrics Soc'y,
vol. 68, no. 9, at 1899 (Sept. 2020), https://
agsjournals.onlinelibrary.wiley.com/doi/epdf/10.1111/jgs.16689;
Charlene Harrington et al., Nursing Staffing and Coronavirus Infections
in California Nursing Homes, Policy, Politics, and Nursing Practice,
vol. 21, no. 3, at 174 (2020), https://journals.sagepub.com/doi/pdf/
10.1177/1527154420938707.
\9\ Yue Li et al., COVID-19 Infections and Deaths Among Connecticut
Nursing Home Resident: Facility Correlates, at 1903, https://
agsjournals.onlinelibrary.wiley.com/doi/epdf/10.1111/jgs.16689.
\10\ Yue Li et al., Racial and Ethnic Disparities in COVID-19
Infections and Deaths Across U.S. Nursing Homes, J. Am. Geriatrics
Soc'y, vol. 68, no. 11 (Nov. 2020), https://pubmed.
ncbi.nlm.nih.gov/32955105/.
\11\ Robert Gebeloff et al., Striking Racial Divide: How COVID-19
Has Hit Nursing Homes, N.Y. Times, Sept. 10, 2020, https://
www.nytimes.com/2020/05/21/us/coronavirus-nursing-homes-racial-
disparity.html#::text=the%20main%20story-
,The%20Striking%20Racial%20Divide
%20in%20How%20Covid%2D19%20Has%20Hit,the%20population%20is%20overwhelmin
gly%20
white.
Notably, provider associations acknowledge to a certain extent the
inadequacy of current staffing practices. In a recent policy proposal,
for example, the American Health Care Association (for-profit
facilities) and LeadingAge (non-profit facilities) recognized the need
for around-the-clock registered nurses.\12\ Likewise, LeadingAge
published a report arguing in favor of paying a living wage to direct
care workers.\13\ In each of these instances, however, provider
associations declined to commit to actually taking these positive
steps, which they claim must be contingent upon increased Medicaid
reimbursement rates.
---------------------------------------------------------------------------
\12\ American Health Care Ass'n and LeadingAge, Care for our
Seniors Act, Improving America's Nursing Homes by Learning from Tragedy
and Implementing Bold Solutions for the Future, at 4 (2021), https://
leadingage.org/sites/default/files/Overview%20-%20Care%20for%20
Our%20Seniors%20Act.pdf.
\13\ Christian Weller et al., LeadingAge, Making Care Work Pay: How
Paying at Least a Living Wage to Direct Care Workers Could Benefit Care
Recipients, Workers, and Communities, at 30 (2020), https://
leadingage.org/sites/default/files/Making%20Care%20Work%20Pay%20Report.
pdf.
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Nursing Homes Create Complicated Corporate Structures to Hide Profits.
The recent congressional hearings shone a light into common nursing
home business practices that frustrate sane public policy. In
particular, testimony submitted to the Oversight Subcommittee of the
House Ways and Means Committee showed how nursing homes use corporate
organizational structures to hide profits.\14\ Similarly, a recent
academic paper demonstrated how private equity investment in nursing
homes has led to a deteriorating quality of care, including unnecessary
deaths, increased use of dangerous psychotropic medications, declining
mobility, and increased expense.\15\
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\14\ See Written Testimony of Ernest C. Tosh, Statement of Sabrina
T. Howell, Ph.D., and Written Testimony of David E. Kingsley, Ph.D. Mr.
Tosh and Prof. Howell also testified in person at the hearing.
\15\ Atul Gupta et al., Does Private Equity Investment in
Healthcare Benefit Patients? Evidence from Nursing Homes, at 3 (Feb.
2021). The findings of this study constitute much of the material
presented by Prof. Sabrina Howell (one of the study's co-authors)
during the recent hearing in front of the Oversight Subcommittee of the
House Ways and Means Committee.
In testimony submitted to the Oversight Subcommittee, Ernest Tosh
clearly explained the gaping holes exploited by the nursing home
industry. First, nursing home business practices have corrupted the
cost reporting required by CMS. As Mr. Tosh reports, ``[o]n the surface
the financial information appears to be useful, until one realizes the
financial picture of a single facility can be highly manipulated if it
is within a chain of nursing homes that also contains multiple related
corporations.''\16\
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\16\ Tosh Written Testimony at 2.
These cost reports may show, for example, that a nursing home has
annual revenues approaching ten million dollars, but nonetheless is
losing money and has relatively few assets. At first glance, such a
nursing home may appear to be in precarious financial shape, but that
first glance does not take into account the nursing home's many
``related party'' transactions. The ``related parties'' are other
corporations owned by the same persons or entities that own the nursing
home. By contracting with the related parties to provide various
aspects of the nursing home's operation--the building itself, for
example, or management services, nursing services, or therapy
services--the nursing home can claim expenses even though it is
essentially paying itself. This allows a nursing home with few assets
and purported annual losses to continue operating successfully: the
overall corporate structure is profitable, even though the entity
holding the nursing home license consistently claims losses.\17\
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\17\ Tosh Written Testimony at 2-6.
The written testimony of David Kingsley highlighted a related problem:
nursing homes' frequent use of real estate investment trusts (REITs).
REITs are used in a common type of related party transaction--the
nursing home operator transfers the real property into a REIT, and then
leases back the property from the REIT, claiming rent payments as
expenses. Like all related party structures, the REITs create false
expenses that are actually just transfers within a single corporate
structure.\18\
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\18\ Kingsley Written Testimony at 2-4.
Mr. Kinsley aptly characterizes the nursing home business as ``a
financial engineering industry engaged in trading property as a
commodity and tax arbitrage as a core technique.''\19\ The web of
related party transactions has no justification from a health care
perspective. Indeed, to a significant extent, the provision of care--
and the quality of such care--is a secondary concern in such business
models.
---------------------------------------------------------------------------
\19\ Kingsley Written Testimony at 5.
Congress Should Provide Better Access to Medicaid-Funded At-Home Care,
---------------------------------------------------------------------------
and Limit Nursing Homes' Use of Deceptive Corporate Structures.
We make two recommendations to improve care for older Americans in need
of daily care. First, Congress should improve access to Medicaid-funded
home and community-based services, so that no one is forced to live in
a nursing home if they would rather receive necessary services at home.
Under current federal law, a state Medicaid program must offer nursing
home care to every qualifying person, but home and community-based
services can be subject to a waiting list or other limit on
enrollment.\20\ Congress should make home and community-based services
available to all persons qualifying under Medicaid rules. Such equal
access to home and community-based services would provide the dual
benefit of enabling persons to receive necessary services at home, and
give nursing homes a greater incentive to offer quality care and a good
quality of life, in order to compete with home and community-based
services.
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\20\ 42 U.S.C. Sec. Sec. 1396d(a)(4)(A) (obligation to provide
nursing home services), 1396n(c) (home and community-based services
waivers).
Second, as set forth in this statement, Congress should take steps to
prohibit the financial machinations that distort the business of
providing nursing home care. Under current business structures, many
nursing homes are focused not on providing high quality care, but
rather on funneling profit out of a nursing home to related parties.
These practices penalize both residents and staff members, and
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inevitably lead to deterioration, injuries and deaths.
Also, as addressed above, these financial structures prevent honest
evaluation of the adequacy of Medicare and Medicaid reimbursement
rates. From our perspective, an increase in Medicaid rates could almost
never be justified under current practices, because nursing home
operators are not being forthcoming about their true financial status.
On a closely related matter, we support calls for greater transparency
in nursing home finances, but are skeptical as to whether transparency
alone can address the current problems. It is not realistic to expect
CMS to perform forensic accounting on the incredibly intricate
corporate structures in use today.
And, finally, we assert that it is entirely fair to prohibit certain
corporate structures as a condition of Medicare or Medicaid
certification. Nursing homes rely on public funding for the bulk of
their revenue.\21\ Given that relationship, along with the importance
of setting appropriate Medicare and Medicaid reimbursement rates, it
would be eminently reasonable for Congress to prohibit the corporate
structures that currently hamper our ability to make meaningful
reforms.
---------------------------------------------------------------------------
\21\ See, e.g., Medicaid's Share of Nursing Home Revenue, Resident
Days Hits Record High as Medicare Drops to Historic Low, Skilled
Nursing News (Dec. 11, 2019) (Medicaid and Medicare funding
constituting over 72% of overall nursing home revenue) https://
skillednursing
news.com/2019/12/medicaids-share-of-nursing-home-revenue-resident-days-
hits-record-high-as-medicare-drops-to-historic-low/.
______
Letter Submitted by Lydia Nunez Landry
Chairman Wyden, Ranking Member Crapo, and distinguished Members of the
Committee,
My name is Lydia Nunez Landry and I am writing to you today not as
someone the American Health Care Association and LeadingAge would
reduce to the characterization (in their ``Care for Our Senior's Act'')
\1\ of a ``frail [or] elderly adult with underlying health conditions''
at risk of dying from COVID ``630 times higher than an 18 to 29'' year
old, that is, someone these lobbyists designate as prone to death.
Rather, despite reductions of people like me--or any other marginalized
group--to underlying health conditions or comorbidities or biased
stereotypes, I write to you today as an alive and thriving disabled
woman, one who lives in and contributes to her community, and as
someone who questions the motives of those who attribute grave
injustice to exploited or oppressed people's own supposed deficiencies.
Without a supportive partner to care for me in our home, I could as
easily have died from neglect or COVID-19 in the average nursing home.
My point here is to show that the long-term care industry is peddling
this narrative simply to avoid responsibility for wrongdoing; that is,
they want to pretend that people are dying in their facilities not
because of the industry's negligence, greed, or malfeasance, but
instead because disabled and older people have a particular tendency to
die en masse. The narrative in ``Care for Our Senior's Act'' is yet
another example of the industry's connivery and manipulation (I will
append a brief example at the end of my testimony to show how they
advance this narrative by playing with statistics).
---------------------------------------------------------------------------
\1\ https://www.ahcancal.org/Advocacy/Documents/
Care%20for%20Our%20Seniors%20Act%20
-%20Overview.pdf.
Generally speaking, when any group of people are marked as suspect or
inferior \2\ in some manner, when they are segregated and denied the
resources \3\ and liberties that others enjoy, their flourishing will
indeed be impeded,\4\ and they will be at a greater risk of contracting
infections or disease. This is evidenced throughout history from the
decaying and dank tenement houses of the early 19th century,\5\ the
horrific conditions of the Warsaw ghetto,\6\ to the abuses that
occurred in state institutions \7\ for people with disabilities. Given
a deadly pandemic combined with deplorable (or at best unsafe)
conditions, where people are segregated and treated as fungible objects
from which to extract government benefits \8\ (or cheap labor), even
AHCA and LeadingAge lobbyists like Mr. Mark Parkinson or Mr. David
Gifford might be at a mortality risk 630 times higher than 18 to 29
year olds not forced to endure similar circumstances. (The industry's
claims are rarely supported by evidence, and with brief examination,
can be shown inaccurate. Their act is at best slipshod and indicates an
arrogance reinforced by years of overindulgence and a lack of
accountability.)
---------------------------------------------------------------------------
\2\ https://press.rebus.community/
introductiontocommunitypsychology/chapter/oppression-and-power/.
\3\ https://www.who.int/disabilities/world_report/2011/
accessible_en.pdf.
\4\ https://www.ama-assn.org/delivering-care/patient-support-
advocacy/how-racism-segregation-drive-health-disparities.
\5\ https://socialwelfare.library.vcu.edu/issues/poverty/tenement-
house-reform/.
\6\ https://www.iwm.org.uk/history/daily-life-in-the-warsaw-ghetto.
\7\ https://files.eric.ed.gov/fulltext/EJ844468.pdf#page=6.
\8\ https://prospect.org/familycare/the-corporatization-of-nursing-
homes/.
In contrast to those who are key players on K Street or spend most of
their time in boardrooms or lobbying in the halls of Congress, I want
to emphasize that my perspective is informed by my advocacy work in
nursing homes where I have spent a great deal of time. I form bonds
with residents. I know many of their spouses and children's names,
where they were from, the hobbies they enjoyed, and the kind of work
they did. All of this they generously shared with me. I learned what it
was like working in a Pennsylvania textile mill in the 1930s, surviving
a chemical plant explosion in Texas and the revolution in Cuba, and
growing up in Mexico in the 1940s. I have heard stories from war brides
from France and Vietnam or the time a woman had to sew thousands of
sequins by hand on her daughter's quinceanera dress. I feel myself
privileged to be granted the opportunity to listen. And unlike CEOs who
earn $1,427,192 \9\ for lobbying, state ombudsman programs rely on
volunteers. I have dedicated my life to this issue and yet rare is the
occasion that I am asked to contribute to this topic. I--and other
disability justice activists--have not been lavished the same platforms
to speak given to long-term care industry CEOs and lobbyists. As a
result of this, the voices of significantly disabled people, those at
imminent risk of institutionalization or those in institutions, are
squelched by the industry narrative. When I initially started out as
ombudsman, I applied the principle of charity to the industry's
narrative, but with careful appraisal of the incongruity between what
residents, families, ombudsmen, advocates, experts, HHS regulators,
CNAs, CMS, and the OIG evidenced compared to the industry's slant, it
became apparent that industry representatives either have a deficient
understanding of the culture and operations their business practices
engender, or worse, they are impervious to the suffering of disabled
people. Choosing not to see injustice or corruption, however, seems
contrary to their lofty mission statements and commitments they have
made to taxpayers.
---------------------------------------------------------------------------
\9\ https://nonprofitlight.com/dc/washington/american-health-care-
association.
On occasion, circumstances force us to confront the ugliness and
brutality that inevitably festers where we sequester vulnerable people;
stories of abject cruelty rip away the veil of inattention we cultivate
to block from our view the relentless mill of everyday abuse, neglect,
and hopelessness. In these moments of outrage, we perceive the true
nature of institutionalization and perhaps even what we must do, but
those flashes of insights quickly fade. Soon those with vested
interests haul out the timeworn reform narratives and ``bad apple''
scapegoats that persuade us to look away again, to participate in
---------------------------------------------------------------------------
systemic neglect from afar.
As an LTC ombudsman I could not simply look away from the toll of daily
abuse and neglect residents experience or ignore their justified
feelings of abandonment and the despair it begets. My ombudsman work
bears out what ought to have long been obvious to any attentive person,
namely, that segregating people in institutions can never foster or
indeed ever permit equal treatment.\10\ Nor--as over a hundred years of
disability history attests \11\--can this model be fixed through
reform. We cannot fix that which, by its nature, leads to systemic
human rights violations. Severing people (like older and disabled
people) from their homes and communities necessarily devalues them as
persons and citizens. The diminishment is felt immediately. The
freedoms they enjoyed vanish as institutional regiments constrict the
courses of their lives. These utilitarian routines deprive them of
their privacy and autonomy for the sake of efficiency and cost-
effectiveness. Confined in these facilities without the projects and
relationships that endowed their lives with meaning and shaped their
social identities, they experience a kind of social death.\12\ And so
too their former communities, continuing on without them, lose the
connection to them as full persons still deserving of the moral
consideration and respect we are obliged to confer on those people in
the community. Isolated, powerless, and dehumanized, people
institutionalized inevitably suffer grave harms, not only from abuse
and neglect, but from the very act of banishing them from the moral
communities that granted the rights and benefits they are now denied.
---------------------------------------------------------------------------
\10\ See, for example, Liat Ben-Moshe, Decarcerating Disability:
Deinstitutionalization and Prison Abolition (Minneapolis, MN:
University of Minnesota Press, 2020).
\11\ Sara F. Rose, No Right to Be Idle: the Invention of
Disability, 1840s-1930s (Chapel Hill, NC: The University of North
Carolina Press, 2017).
\12\ 3Jana Kralova, ``What Is Social Death?'' Contemporary Social
Science 10, no. 3 (2015): pp. 235-248, https://doi.org/10.1080/
21582041.2015.1114407.
To be sure, congregate institutions try to simulate community to hide
these realities, but such ersatz contrivances are no substitute for
genuine social inclusion and belongingness; the simulations are
parodies. Such a model cannot produce ``person-centered care'' no
matter how many CMS regulations we enact and enforce. Nor can quarterly
congressional hearings \13\ and regulatory tweaks \14\--informed by the
usual actors \15\ they serve to benefit--amount to anything more than
theater, political performances that strike those people who must
endure the injustice \16\ as thoughtless cruelty.
---------------------------------------------------------------------------
\13\ https://www.finance.senate.gov/hearings/a-national-tragedy-
covid-19-in-the-nations-nursing-homes.
\14\ https://www.kxan.com/investigations/obscure-program-sends-big-
money-to-texas-nursing-homes-amid-pandemic-is-it-protecting-residents/.
\15\ https://www.npr.org/2020/05/21/855821083/ideal-nursing-homes-
individual-rooms-better-staffing-more-accountability.
\16\ https://www.cnn.com/interactive/2017/02/health/nursing-home-
sex-abuse-investigation/.
Only a transformative shift in public policy can end these injustices.
This shift will require scrutinizing narratives widely considered
axiomatic. These include the beliefs that institutionalization is an
unavoidable consequence of aging \17\ and disability, that institutions
provide safer \18\ environments (a claim long used to rationalize the
barbarity of social removal despite evidence demonstrating the
contrary),\19\ that uprooting people from the homes, communities, and
personal identities they spent lifetimes nurturing is compatible with
our most revered social ideals, and finally that we can outsource our
humanity--that is, our moral and social obligations to one another,
including our disabled parents and children--as a revenue source for
corporations and the workers they exploit \20\ and expect humane
results.
---------------------------------------------------------------------------
\17\ https://www.irishtimes.com/opinion/nursing-homes-must-be-made-
a-thing-of-the-past-
1.4257422?mode=amp&fbclid=IwAR2NDUH2vj4HrwoBbpOG9iF0SYqz5RM2jTAx4BnYqVe5
MK
BBr--j6Cp6FLY.
\18\ https://oig.hhs.gov/oas/reports/region1/11600509.asp.
\19\ https://www.ncbi.nlm.nih.gov/books/NBK217552/.
\20\ https://www.finance.senate.gov/imo/media/doc/
AdelinaRamos_WrittenTestimony%20
March%2017.pdf.
By now, we know these outcomes of the institutional model; it is a
model that objectifies deeply human concerns and favors economic values
and imperatives such as competitiveness, efficiency, and profit
margins, values that tend to attract predatory actors.\21\ And yet we
persist with it, and one must ask why. Why do we continue to allow
neglect, abuse, and dehumanization to go unchecked? Why do we allow
those same predatory actors to manufacture and control the narratives
\22\ that frame these issues, and indeed provide them platforms \23\ in
the halls of Congress and in the media to influence unwitting
advocates? Why do we persist with this cultivated naivety in the face
of so much everyday suffering? The poor human rights records of
congregate care facilities long predate the COVID-19 crisis, but the
crisis has laid bare \24\ the preexisting conditions that led to deaths
of over 181,000 disabled people in these institutions.\25\
---------------------------------------------------------------------------
\21\ https://www.nytimes.com/2021/03/13/business/nursing-homes-
ratings-medicare-covid.html.
\22\ https://www.finance.senate.gov/imo/media/doc/
FINAL%20Dr.%20Gifford%20SFC%20
Hearing%20Testimony%203.17.2021.pdf.
\23\ https://www.providermagazine.com/Breaking-News/Pages/AHCA,-
NCAL-Head-Parkinson-Named-a-Top-Lobbyist-for-2020.aspx.
\24\ https://www.aclu.org/news/disability-rights/covid-19-deaths-
in-nursing-homes-are-not-unavoidable-they-are-the-result-of-deadly-
discrimination/.
\25\ https://www.kff.org/coronavirus-covid-19/issue-brief/state-
covid-19-data-and-policy-actions/.
The horrors I witnessed as an LTC ombudsman keep me up at night, but
also inform my disability justice work. And both my insomnia and
activism partly derive from frustration. In deference to the industry,
the system defangs oversight. I have fought countless nursing home
attempts to involuntarily discharge residents only to have found that
those residents, some with severe dementia, had disappeared the
following week--to where, the nursing home curiously had (or at least
offered) no clue. Sitting at their bedsides, I have held residents'
hands as they recounted instances of rape and abuse, often by staff.
Residents have had limbs amputated due to a lack of wound care,
understaffing, and poor training. I have seen residents gasp for air as
nursing home staff rationed oxygen to save money. I have called Health
and Human Services on multiple occasions for residents due to cruel
instances of retaliation, only to leave the residents open for more of
the same because they sought assistance from a deliberately debilitated
regulatory system. Finally, I, myself, have been threatened on multiple
occasions by staff and operators. Despite my notifying HHS regulatory
and the Ombudsman Program, nothing of substance was done. To the
industry, ombudsmen are gnats to swat away; they well know consequences
will not be forthcoming. After all, there are few if any consequences
---------------------------------------------------------------------------
for the negligent deaths of residents.
Culture change is impossible within the institutional habitus,
particularly so when professional and agency advancement, corporate
profit,\26\ race, age, and ableism are added to the brew. From the
institutional point of view, the dehumanizing model is working as
intended. Hence, pumping in ever more money to fund the same solutions
and reforms will not bring about different results. As we have seen
during the COVID-19 pandemic, nursing homes made record profits \27\
from taxpayer funded COVID subsidies,\28\ yet COVID cases and deaths,
along with non COVID deaths resulting from inadequate infection control
practices and severe understaffing,\29\ continued to rise.
---------------------------------------------------------------------------
\26\ http://tallgrasseconomics.org/2021/02/1539/.
\27\ http://tallgrasseconomics.org/2021/02/the-ensign-group-
americas-biggest-nursing-home-corporation-had-a-banner-year-in-2020/.
\28\ https://www.mcknightsseniorliving.com/home/news/assisted-
living-eligible-for-20-billion-in-new-relief-funding-for-covid-19-
related-losses-expenses/.
\29\ https://apnews.com/article/nursing-homes-neglect-death-surge-
3b74a2202140c5a6b5cf05
cdf0ea4f32.
---------------------------------------------------------------------------
There will be no substantive change until we end the Medicaid
institutional bias by diverting taxpayer funds away from institutions
and to programs that maintain or reestablish community integration. As
I often explain, nursing homes are the most subsidized \30\ industry in
the United States and increased monetary rewards \31\ serve only to
entrench industry malfeasance.\32\ Diverting Medicaid dollars to fund
HCBS not only reaffirms our commitments to the Americans with
Disabilities Act (ADA), the Supreme Court's Olmstead decision, and our
professed democratic principles, it will also do more to soften the
resolve of a recalcitrant industry (and similar nonprofits) than years
of congressional hearings. In the long run, we will waste fewer
resources on researching deficient industry practices and developing
complex strategies to instigate change (only to be undone by
lobbyists), on Office of Inspector General (OIG) and the U.S. General
Accounting Office (GAO) investigations, on Ombudsman programs, on
regulatory agencies to maintain the illusion of oversight, on
healthcare costs resulting from the industry's negligence, and on
subsidizing the industry's cost of doing business.
---------------------------------------------------------------------------
\30\ http://tallgrasseconomics.org/2021/01/the-media-is-promoting-
a-dangerous-false-narrative-by-claiming-that-the-nursing-home-industry-
is-struggling-financially/.
\31\ https://www.mcknightsseniorliving.com/home/news/assisted-
living-eligible-for-20-billion-in-new-relief-funding-for-covid-19-
related-losses-expenses/.
\32\ https://www.youtube.com/watch?v=ee-rnrbrD1g.
---------------------------------------------------------------------------
Sincerely,
Lydia Nunez Landry
Certified Volunteer Long-Term Care Ombudsman
Organizer for Gulf Coast Adapt
Appendix:
As promised, I want to briefly review a few of the rhetorical and
statistical practice employed by the industry and their lobbyists to
reframe the human catastrophe exacerbated by the negligent practices in
LTC facilities. The author of Care for Our Seniors Act,\33\ which
aspires to learn from ``tragedy'' and implement bold solutions,
concedes that LTC facilities were the epicenter of the ``once-in-a-
century'' pandemic's ravage. The force-of-nature language distances the
170,000 deaths (now up to 181,286 \34\ deaths) from any culpable agent.
And indeed, no one is to blame for the virus, just as we can blame no
one for a major flood. But we can blame them for negligent and habitual
substandard practices (such as not maintaining levees) that
substantially worsen the toll. The author mentions ``independent
research'' by ``leading experts'' which shows that ``COVID-19 outbreaks
in nursing homes are principally driven by the amount of spread in the
surrounding community.'' The only actual research offered \35\--
conducted in May, 2020, long before the vast majority of cased
occurred--did conclude that size and location of facilities were
factors while traditional metrics such as star ratings and prior
citation for poor infection control were not. (Most of the citations
were articles from industry magazines, one of which mentioned the
article just cited.) It's unclear how this exonerates the industry.
Moreover, the study, thus interpreted, becomes an outlier, as much more
research has found direct links between poor quality ratings and
significantly higher numbers of COVID cases and deaths (see here \36\
and here \37\).
---------------------------------------------------------------------------
\33\ https://www.ahcancal.org/Advocacy/Documents/
Care%20for%20Our%20Seniors%20Act%
20-%20Overview.pdf.
\34\ https://www.kff.org/coronavirus-covid-19/issue-brief/state-
covid-19-data-and-policy-actions/.
\35\ https://agsjournals.onlinelibrary.wiley.com/doi/full/10.1111/
jgs.16661.
\36\ https://www.sciencedirect.com/science/article/abs/pii/
S0195670121000086.
\37\ https://www.sciencedirect.com/science/article/pii/
S1525861020305211.
Instead of dueling studies, we might focus on statistics. The author
notes another force of nature behind the deaths, namely time: aging and
the fragility of bodies. The virus just happens to target the frail and
elderly adults with underlying health concerns that live in their
facilities. The author incorrectly asserted that the average age of
nursing home residents is 85, but correctly asserted that most
residents have underlying conditions, as indeed most people over 65
years old have multiple chronic conditions, in and out of LTC
---------------------------------------------------------------------------
facilities. First some number:
The U.S. has approximately 52 million citizens aged 65 or greater. Of
them, 430,000 have died from complications of COVID-19 infections. Of
those, 130,000 died in nursing homes--the author mention 170,000
deaths, but that includes congregate facilities the data from which is
sparse, so I shall stick with the 130,000 in nursing homes (NHs). Thus,
300,000 died elsewhere than a NH. NHs warehouse approximately 1.4
million residents, 90% of whom are 65+ years old. The total number of
cases in NHs is, at the moment, 643,314, and, for non-NH people in the
same age group, 2,666,625. Looking at the bare infection and death
numbers, one might think that nursing homes did well--too well, in
fact, for the author's contentions.
But consider again that most people over 65 years old have chronic
conditions and most people, even with their bleach wipes, have
rudimentary infection controls in their homes. Now, 9.28% of the 1.4
million people in NHs have died from COVID; we can round that up to 1
in every 10. But if non-NH people in the same fragile age group died at
that rate, we would have an incredible 4,342,857 more deaths than we
do, as only 1 in 167 non-NH elderly people died from COVID. Indeed,
examining only those infected, you are nearly twice as likely to die
(20% vs. 11%) if you're in a NH than not. Indeed, the infection rate in
NHs is 46% vs. 5.3% for non-NHs fragile people.
Now, ultimately, industry spokespeople will claim that the deaths
occurred because all these people are interacting in close quarters,
and so on. But this is not something that can be fixed, and so it
underscores why we need to turn back to community integration instead
of warehousing people in admitted death traps.
______
LeadingAge
2519 Connecticut Avenue, NW
Washington, DC 20008-1520
P 202-783-2242
F 202-783-2255
LeadingAge.org
Thank you for the opportunity to comment on the above hearing. Our
members and the older adults they serve have been irrevocably affected
by this pandemic. We appreciate the concern that this Committee has
expressed over the past year and its efforts to address the significant
challenges posed by both public and private responses to the public
health emergency.
LeadingAge is a tax-exempt national organization focused on education,
advocacy, and applied research. The mission of LeadingAge is to be the
trusted voice for aging. Our 5,000+ not-for-profit members include the
entire field of aging services providers--nursing homes, home care and
hospice, affordable housing, life plan/
continuing care communities and assisted living.
We begin our statement by asking the most difficult question, what
happened?
If only it were easy--if only there was an answer to the question, what
happened? Why did so many people die in nursing homes? What magic
bullet could we have fired to prevent this? What magic bullet can or
should we look to in the future?
As Dr. Tamara Konetzka testified, based on her rigorous, highly
respected research, ``the two strongest and most consistent predictors
of worse COVID-19 outcomes are nursing home size, with larger
facilities being more at risk, and COVID-19 prevalence in the
surrounding community,'' as opposed to star rating, staffing, access to
PPE, etc.\1\ The greater the presence of the disease in the community,
the greater the impact on residents and staff. The second condition is
something that we have tolerated for many years--large poorly funded
nursing homes with many residents, many of the long-stay residents poor
and racial minorities, again, at greater risk for this disease for all
the reasons that we know as we attempt to address the impact of
centuries of discrimination. In those communities with the highest
spread, where staff are as affected as residents, the disease was at
its deadliest.
---------------------------------------------------------------------------
\1\ We appreciate that there is research showing that nonprofit
nursing homes and nursing homes with higher rankings, many of whom are
our members, fared better. However, they too faced all the public
health challenges we discuss, herein, and without addressing those
challenges, we consign all nursing homes, even the best performers, to
an intolerable situation.
When Dr. Kontezka was asked, what could have been done to reduce this
tragedy, she responded, better use of public health to control spread
in the community We needed a fast, all of government public health
---------------------------------------------------------------------------
response to contain and control the disease and that did not happen.
This pandemic was a failure of our public health infrastructure, and
that failure trickled down to infect all the public and private health
care and housing entities that supported at risk populations, both
residents and staff.\2\
---------------------------------------------------------------------------
\2\ We note that the negative impact of the pandemic on older
persons and persons living in nursing homes and other congregate
settings, along with public and private response, is not limited to the
United States. A survey conducted by Global Ageing Network,
representing aging services providers throughout the world, revealed
eerily similar experiences. https://globalageing.org/gan-covid-report/.
The underlying challenge to this disease--its very newness--was faced
by all our members. It is called the novel coronavirus for a reason.
Each day brought new knowledge about the disease, but that means that
the day before, we were operating on old and not necessarily accurate
information. For example, during the early days when the pandemic was
new--March and April 2020--a lack of understanding of how the disease
spread resulted in inconsistent and often changing advice (e.g., when
to use masks; testing limited to symptomatic staff and residents,
before we realized it was spread asymptomatically and was not
contained; inconsistent directives from state, local and federal public
---------------------------------------------------------------------------
health authorities).
In addition, the entire health care system was left to fight it out for
essential supplies rather than having a centralized source (indeed,
even FEMA couldn't adequately fulfill the White House's April directive
to send 2 weeks of supplies to nursing homes months into the pandemic.)
Failure of public leadership to understand the disease led to new
problems placed at the feet of nursing homes trying to follow the ever-
changing directives--e.g., closing down nursing homes to visitors saved
lives (because of asymptomatic carriers, speed with which older persons
died from infection) but because we had NO idea how long the crisis
would last, created its own secondary health crisis, isolation.
Why is it so important to stress the public health failures? Because we
must learn the right lessons if we are not going to repeat this
disaster as this public health emergency continues and we also examine
how to avoid future disasters.
To fix public health infrastructure in the future we must have:
Transparency and honesty; credibility of public and private
systems can only be built on a foundation of transparency and open
communication, even but perhaps most importantly when we do not have
answers.
National public reporting system to ensure accuracy and
consistency, including reporting of race, ethnicity, gender and age.\3\
---------------------------------------------------------------------------
\3\ See, e.g., LeadingAge's letter to Sec. Azar asking for a
uniform reporting system. file:///C:/Users/Marsha/Documents/
CDC%20reporting%20letter%20final.pdf.
---------------------------------------------------------------------------
National testing strategy to eliminate duplicative,
contradictory policies; and public financing to ensure that private
entities are adequately compensated for mandatory requirements.\4\
---------------------------------------------------------------------------
\4\ See, e.g., LeadingAge's letter to Congressional leadership,
file:///C:/Users/Marsha/Downloads/Testing%20letter.pdf.
---------------------------------------------------------------------------
Public access to PPE, to eliminate the ``hunger games'' scenario
where providers are mandated to use PPE but PPE is in short supply
globally, leaving providers to find PPE by themselves, hoping their
standard supplier has access or they can find some other supplier who
is reliable and honest. Public access would also reduce the problem of
price gouging, where the cost of a disposable gown increases from 25
cents pre-pandemic to $4.00 during the pandemic. It truly is the
federal government's responsibility to manage access to and
distribution of rare but life-saving essential products.
Emergency preparedness infrastructure must include aging
services. Examples include retaining the strike teams that some states
created earlier in the pandemic (and now funded though CMS); and
effective use of the public health workforce to supplement workers who
are in quarantine or sick leave. This is essential not only for nursing
homes but all congregate and senior housing, including HUD housing
where low-income seniors at highest risk live in the ``community'' but
with little access to necessary services (e.g., Wi-Fi, access to
testing and vaccines). Aging services providers must be at the table at
all levels. This is the lesson we thought was learned from Katrina, but
it is not clear we did.
Telehealth/technology/broadband issues of fairness and access
remain. We clearly need to improve broadband access in rural areas;
provide access to reduced rates for rural home health providers as we
do for nursing homes; reimburse telehealth capabilities in non-rural
nursing homes and other care settings; and address access and
availability in community settings, for example by allowing HUD housing
providers to wire their apartment buildings for Wi-Fi for tenants.
Effective public/private partnerships. The long-term care
pharmacy partnership to deliver vaccines to almost every nursing home
is a good example of the federal approach that has been sorely missing.
While not perfect, with improvements it could be a model for addressing
specific needs in future emergencies.
The second cause identified by Dr. Konetzka--large poorly funded
nursing homes--embodies long-standing challenges to the way we deliver
long-term services and supports. To address these issues, we must:
Focus on long-stay residents--financed through Medicaid and to a
much smaller extent, private pay--and rebuild our communities to
address the social and health needs of these residents.
Rethink how nursing homes are conceived and structured, moving
to a smaller setting, with single rooms, again focusing on the needs of
long-stay residents;
Address workforce issues; the continual shortage of qualified
staff at all levels and the serious underpayment especially at the
direct care worker level must be addressed; LeadingAge's Center for
Workforce Solutions \5\ and the LeadingAge LTSS Center@UMass \6\ are
both dedicated to identifying solutions to these issues.
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\5\ https://leadingage.org/workforce.
\6\ https://www.ltsscenter.org/.
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Address critical financing issues associated with under-payment
from Medicaid and the negative impact that underpayment has on quality
and services. LeadingAge members regularly report that they must raise
millions of dollars annually through charitable donations to provide
high quality care because of underfunding from Medicaid.
Recognize that nursing homes are part of a continuum of services
primarily financed by public programs. We critically need a non-means
tested public long-term care insurance program to ensure that all
persons have an affordable means of paying for long-term care, are able
to age or live with disability in the setting of their choice for as
long as they can, with both quality of life and quality of care.
In addition, witnesses at this hearing and at other hearings before
this committee and the Special Committee on Aging have raised concerns
about how to ensure nursing homes provide high quality care, and how to
respond to nursing homes that are poor performers.
Care for Seniors, the 8 point program LeadingAge and AHCA have put
forward, addresses many of the concerns raised during this hearing, and
identifies public and private financing mechanisms to implement these
policies.\7\
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\7\ https://leadingage.org/care-our-seniors-act.
1. To enhance quality of care:
a. Enhanced Infection Control: we strongly agree that
infection control is critical and have proposed updating the current
guidelines to address some of the challenges around workforce and
training to make it possible to employ infection control specialists in
each nursing home.
b. RN 24/7: many of our members already employ registered
nurses on a round-the-clock basis. In many parts of the country,
however, there is a shortage of qualified nursing staff, and Medicaid,
the primary payer for long-stay nursing home residents, is not funded
in a way that covers current costs, much less the addition of, in
effect, 6 full time nurses just to have one nurse on staff all the
time. We provide a number of recommendations on how to implement
expanded staffing.
c. Maintaining a minimum 30-day supply of PPE, to address
current and future infectious diseases and other conditions that
require extensive protective equipment. Again, this will require not
just action by nursing homes but also a commitment from the public
sector to ensure that adequate supplies are available continually.
2. Recruit and Retain a Long Term Care Workforce Strategy:
a. For decades the nursing home field has been plagued by
shortages in staff, whether because it is easier and more lucrative to
work in settings like hospitals, as Ms. Ramos so accurately testified,
or because there simply are not sufficient numbers of persons
interested in this field. As mentioned above, LeadingAge's Center for
Workforce Solutions and LTSS Center have been working on attracting
workers for many years, culminating in the ground-breaking work, Making
Care Work Pay, which addresses the economic benefits and necessity of
providing a living wage, along with the challenges of implementing this
policy.
b. Care for Seniors recommends a multi-phase tiered approach
to supply, attract and retain the long term care workforce, including
leveraging federal, state, and academic entities to provide loan
forgiveness for new graduates who work in long term care, tax credits
for licensed long term care professionals, programs for affordable
housing and childcare assistance, and increased subsidies to
professionals' schools whose graduates work in nursing homes for at
least 5 years.
3. Improve Systems to be More Resident-Driven
a. Survey Improvements for Better Resident Care: Over many
years, numerous studies by private and public entities have documented
failures in the survey system, from inconsistent results to failure to
identify and fix significant deficiencies. This over 30-year old system
needs to be revamped to reflect modern thinking on addressing medical
errors (e.g., using the elements in the patient safety model) and the
significant changes in nursing homes and the residents we serve since
this system was inaugurated in 1987. LeadingAge strongly supports the
study currently undertaken by the National Academies of Science,
Engineering and Medicine (NASEM) reexamining the current way we
identify, measure and enforce quality of care and quality of life in
nursing homes.\8\ Additionally, Care for Seniors makes recommendations
that support development of an effective oversight system and processes
that support improved care and protect residents.
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\8\ https://www.nationalacademies.org/our-work/the-quality-of-care-
in-nursing-homes.
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b. Chronic Poor Performing Nursing Facilities and Change of
Ownership: A corollary of the failure of the current survey and
certification system is the continued and seemingly intractable problem
of chronic poor performers. LeadingAge supports the Nursing Home Reform
Modernization Act (S. 782) introduced by Senators Casey and Toomey as
an excellent example of a creative way to address improving care by
creating a separate program within CMS to provide mandatory counseling,
education and assistance for poor performers. In Care for Our Seniors,
we propose a detailed process for working with poor performers: (1)
Identify chronic poor performing facilities; (2) Conduct an analysis to
determine the reason for chronic poor performance; (3) Develop a turn-
around plan; (4) Monitor progress; and (5) Determine if the plan of
correction goals have been met or the need for plan revisions. Finally,
we ``bite the bullet'' and state, ``If milestones are not met within
six to 24 months (median time of one year), a temporary manager, change
in management/ownership or the closure of the facility may be
required.''
c. Customer Satisfaction: As we note in this last
recommendation, nursing homes are the only Medicare health care
provider that does not include customer satisfaction in the data
collected and reported by CMS. Hospitals, hospice, and home health
collect customer satisfaction, which is part of their publicly reported
data. We recommend adding a customer satisfaction measure to the 5-star
rating system, to help consumers and family members monitor the quality
of nursing homes.
Finally, we should use this crisis as an opportunity to think more
broadly about how we want to age, what services we will need in the
future, how we will want to live, and how we expect to finance the
aging services ecosystem. While we understand the importance of
addressing care in nursing homes during the pandemic, we would note
that more older adults live in the broader community than in nursing
homes. We have very little data on the impact of COVID on older adults
who receive LTSS in the community.
We must, therefore, also address loss of community-based services.
Closure of adult day programs, PACE, senior centers, loss of access to
HCBS and home care workers all had a negative impact on seniors now and
will in the future. LeadingAge members who provide home-based care,
whether through Medicare, Medicaid or private pay, had trouble
accessing PPE, testing, and vaccines, which would be essential to their
being able to serve their clients. The adults we serve as well have had
difficulty being prioritized for testing and access to vaccines,
especially home-bound clients. In this respect, a more robust public
health infrastructure, with community mobile clinics, is critical, as
well as addressing the needs of individuals in HUD-supported housing.
In conclusion, we thank you for the opportunity to engage in this very
critical endeavor, improving the care and services our provide to the
most vulnerable and frail in our society. This pandemic has been
devastating to the people we serve, our staff, and our leadership. We
must learn the right lessons so that we are able to come out of this
crisis stronger and able to provide older adults with true quality of
life and services.
______
Letter Submitted by Carrie Leljedal
A National Tragedy: COVID-19 in the Nation's Nursing Homes
Wednesday, March 17, 2021
To: Senate Committee on Finance
Thank you for allowing me to submit a statement in regard to the COVID-
19 crisis in Skilled Nursing Facilities (SNF) in the United States. My
name is Carrie Leljedal, and I have a 33-year-old son who resides in an
Intermediate Care Facility for adults with Developmental Disabilities
(ICFDD), Skilled Nursing.
I am also the leader for Illinois Caregivers for Compromise, we
advocate for residents and families in all kinds of residential long-
term care facilities (LTCF) in Illinois, and with our National Chapter.
Recently, I started volunteering with the Illinois Ombudsman office.
When most families must deal with long-term care it is for less than 5
years. I am in this for the long haul, my son will always require
skilled nursing he has resided in his facility for seven and half years
and could easily be there another 40-50 years.
My Lynn, was born with a rare seizure disorder, called Sturge-Weber
Syndrome (SWS) and a host of other serious health conditions. Lynn has
had over 100 surgeries in his life, and close to 45 hospital stays.
Lynn is currently followed by three different kind of neurologist,
three different eye doctors, two endocrinologist, one GI doctor along
with both physical and psychologist therapist. One of the biggest
issues we face early on into the pandemic was we had to cancel all of
Lynn's doctor's appointment.
Lynn has lived in his ICFDD in Southern, Illinois. On March 9, 2020, I
received a call from the Executive Director telling me that the county
health department was restricting all visitors to the facility. Five
days later, CMS issued guidance on March 13, 2020 to shut down all
facilities to anyone who was not employed at the facility.
I had seen Lynn on March 9th and was unable to see him again until late
June, I do not consider virtual, or window visit a visit to see my son.
When I finally was able to see my son, it was only at doctors'
appointments and I was required to stay 6 feet away, socially
distanced. When I met him at his ICFDD, for his first post quarantine
doctor's appointment the ED came outside and informed me that I was not
allowed to hug or kiss my son, I was an inch shy of fully
hyperventilating while driving to follow them to the doctor's
appointment. Explaining to my son, why I could not hug or kiss him was
exceedingly difficult for both of us.
In a years' time, my son has been able to come home for three different
long weekends, when returning to the ICFDD, he was required to
quarantine for 14 days. I have been told, that would continue even
though he is fully vaccinated and so are my husband and myself.
Residents of LTCF, have suffered in ways that will take us years to
fully understand. The fear of the unknown might have been one of the
hardest parts of this. My son is verbally high functioning and
understands things well, as much as he understood why he had to be
quarantined it still affected him mentally and physically. Early on as
COVID first entered the building, my son would ask me if I knew which
of his friends had tested positive and if anyone had died. Never did I
think this would be a regular question from my son. Explaining all of
this to an adult who functions at around a 10-12-year-old level was
quite difficult.
CMS issued some visitor guidance on September 17th, the guidance was
extremely limited, but it was a start, until the states got their hand
on it. As the leader of the Illinois Caregivers for Compromise, I heard
from members all over Illinois and with leader of the other states. CMS
guidance did little to nothing to assist residents with being able to
see their family members. Many states would only allow for
compassionate care visit, at end of life and still required family
members to remain socially distanced from their loved ones. The number
of people that have died alone in the US over the past year, because
hospitals and long-term care facilities would not allow family members
to remain until the end is unfathomable.
September 17th guidance allowed for outside visits for residents and
family members. This was set up to fail on day one. By the time you
require 6 ft social distance and barrier and masks between the resident
and the visitor, most residents could not hear the visitor and or
recognize them.
The director of Nursing Homes Division for CMS, Evan Shulman, has
publicly stated multiple times that he has heard from residents that
they would rather die from COVID-19 than go another year without seeing
family.
The effects the isolation has caused on residents of all kinds of long-
term care facilities in the United States is cruel and unusual
punishment. Why are we punishing some of our most fragile residents in
the United States, who need extra care to live.
Are you aware that long term care effects every age? There are children
who can spend years in long term care because they require more medical
care than a parent can provide at home, but not enough to keep them in
a true hospital setting. Adults with developmental disabilities (DD)
usually enter long-term care in their late teens or early twenties and
remain there the rest of their lives. Even residents of adult DD
community living arrangements have been isolated from their families
this last year.
Early in the pandemic, the mandated quarantine of residents on any kind
of long-term care facility made sense. One we where past the first few
months and had reliable testing and PPE the residents should have had
as many of their rights restored as possible. Residents of long-term
care are entitled to the same freedom and right to make their own
choice as any other resident of the United States. There could have
been many ways to restore some of the resident's rights to allow some
visitors, using common sense and core safety protocol, while treating
residents and family members with respect and not like guilty
criminals.
A year later, with new visitation guidance in place that does allow for
visitation and physical contact, most facilities and quite a few States
are making their own rules and in turn they continue to violate the
resident's rights. If I had to guess over 50% of residents in long-term
care have not seen a family member or friend in over a year without a
window between them and a supervised visit as if they where in prison.
There are so many things that have gone wrong over the past year in
long term care, we all know that the entire system from pediatrics to
geriatrics needs a complete overhaul. To do this and to do it right,
you need all stake holders at the table. The fact that there was not a
single resident or family members asked to give testimony during the
public hearings speaks volumes as to where they stand.
In Missouri and Illinois, CMS issued penalties to 258 nursing homes
during 2020 and earlier this year for infection control deficiencies.
Of those, 220 also received incentive payments for low COVID-19
transmission rates.
The largest infection control-related penalty for any nursing home
across the two states in 2020 went to Life Care Center of St. Louis.
CMS issued a penalty of almost $500,000 in May for issues that
inspectors said ``placed all residents in the facility in immediate
jeopardy.''\1\
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\1\ https://www.medicare.gov/care-compare/inspections/pdf/nursing-
home/265610/health/infection-control?date=2020-05-18.
So far, Life Care Center has reported eight residents' deaths due to
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COVID-19 to CMS.
In October, the facility received nearly $60,000 in incentive payments.
At Crystal Creek Health and Rehab Center in Florissant, 13 residents
died of COVID-19. For infection control deficiencies in February and
September 2020, CMS issued a $153,842 penalty. The next month, Crystal
Creek received an incentive payment from HHS. By December, the
incentive payments totaled $146,088, almost completely wiping out the
penalty.
Across Missouri and Illinois, almost 200 nursing homes received
incentive payments that were greater than their infection control-
related penalties from 2020 or 2021.
A statement from the Health Resources and Services Administration,
which administers the incentive program, said that there are two
criteria for an actively certified nursing home to receive an incentive
payment: ``First, a facility must demonstrate a rate of COVID-19
infections that is below the rate of infection in the county in which
they are located. Second, facilities must also have a COVID-19 death
rate that falls below a nationally established performance threshold
for mortality among nursing home residents infected with COVID-19.''
However, the calculations for the incentive payments do not take into
account \2\ whether a facility has a previous or ongoing deficiency
from a CMS inspection.
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\2\ https://www.hrsa.gov/sites/default/files/hrsa/provider-relief/
nursing-home-qip-methodology.pdf.
Instead of giving bonus payments to the nursing homes, they could have
used those monies to require more staff to be hired and people given
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jobs and the residents would be safe.
An HRSA statement said the incentive money must be spent in certain
ways: ``Nursing home QIP recipients must utilize the resources they
receive to continue to protect their residents and staff against this
devastating pandemic and they must attest to the terms and conditions
outlined in the program for payment. For example, quality incentive
payments may be used for costs associated with administering COVID-19
testing for both staff and residents; reporting COVID-19 test results
to local, state, or federal governments; hiring staff to provide
patient care or administrative support; efforts to improve infection
control, including activities such as implementing infection control
'mentorship' programs with subject matter experts, or changes made to
physical facilities; and providing additional services to residents,
such as technology that permits residents to connect with their
families if the families are not able to visit in person.''
We need a complete overhaul of the long-term care system in the United
States. The priority must be quality of life for the residents. The
fact that we have lost over 150,00 residents in Long-Term Care due to
COVID-19 proves we can not protect than from COVID. The number of
people who died from Isolation, Failure to Thrive, Neglect and Abuse
might never been know, but by protecting them to death we took away any
quality of life that they might of had.
I am begging all of you, put yourself in my shoes, imagine knowing your
child will live in long-term care for another 40-50 years, would you
want them to go through another year like 2020. If we can find a way to
bring the right people to the table, we can find a way to better the
system to prevent anyone from having to relive 2020.
Sincerely,
Carrie Leljedal
______
Statement Submitted by Ja'Nisa Mimbs
My Mother is in Eastview Nursing Center in and we've not been allowed
to touch or spend any valuable time with her since February 19, 2020.
We've visited at her window, which they refuse to even crack for her to
hear us. Then they started these outdoor visits for 30 minutes. Keep in
mind, it was on Tuesdays and Thursdays from 9:00 a.m.-10:00 a.m. and
4:00 p.m.-5:00 p.m. That's eight visits a week for the entire nursing
home, you had to make a reservation and pray you got a spot. The visits
were outside with a table between us and an aid watching our every move
to ensure we didn't touch her. They stopped those visits in September
and just started them back on March 1, 2021.
My Mother was walking with a walker, dressing herself, using the
restroom, feeding herself and needed little assistance with her daily
activities. In October she started to decline, she had a severe UTI
that had gone unnoticed by the staff and as we weren't allowed to spend
anytime with her, we couldn't alert them that something was wrong. By
the time it was caught, it was severe! She was very confused, was
incontinent and in a diaper. Something she'd never been before. They
gave her the antibiotic Vancomycin intravenously and it was so strong
it almost killed her. She was so weak and she's never come back from
it. This was the start of her decline in October, we were never allowed
Compassionate Care Visits to try to boost her spirits and entice her to
improve. Yet they tell us she's depressed, not eating and they're
putting her on an antidepressant. At this point she was not walking,
any longer and was placed in a wheelchair. She was moving herself
around in her chair with her feet and was still getting up every day.
Then it got to where they were leaving her in her wheelchair all day
while she's complaining that her bottom hurt and we now have a bedsore
on her bottom. Thanksgiving Day we visited at her window and they
allowed me to give her a plate of banana pudding, she sat and fed
herself the entire plate. Many visits at her window in the cold with my
78-year-old stepfather is all we had. Christmas Day, again, a plate of
food, she fed herself and by mid-January she was bed ridden, she's now
in the bed being turned every 2 hours from side to side to help the
bedsore, she's 90 pounds, now on pureed foods, being fed and can do
nothing for herself not even hold a cup of water. We've signed the
paperwork as last week (March 8, 2021) to put her on Hospice, at the
advice of the nursing home physician and we're still not being allowed
Compassionate Care Visits.
We can do the 30-minute visits which they make her get in a geriatric
chair while she complains that it hurts her bottom. We've asked the
administrator about Compassionate Care Visits and were told, they will
do them on Mon., Wed., Thurs., Fri. between the hours of 11:00 a.m. and
4:00 p.m. We must allow the staff to administer a rapid antigen COVID
test, be dressed in full PPE gear (head to toe) and can't touch her,
only sit 6 feet from her in her room, but these have not been arranged
yet. While the staff come and go as they please with nothing but a mask
on.
Also, she's in a room by herself, she's basically quarantined already
and we still can't see her, touch her or speak to her without the staff
monitoring us.
My Mother deserves so much more, all the residents do. Without family,
what quality of life do they have? They've lived their lives and their
only comfort is family and that has been snatched away as they're
treated like hostages and I never thought this world would come to me
having to beg for permission to hug my Mother, care for her, sit by he
side and hold her hand while she leaves this cruel world!
______
National Consumer Voice for Quality Long-Term Care et al.
1001 Connecticut Avenue, NW, Suite 632
Washington, DC 20036
Ph: 202-332-2275
Fax: 866-230-9789
www.theconsumervoice.org
Jonathan Evans, President
Lori Smetanka, Executive Director
March 29, 2021
U.S. Senate
Committee on Finance
Dirksen Senate Office Bldg.
Washington, DC 20510-6200
RE: Statement for the Record: A National Tragedy: COVID-19 in the
Nation's Nursing Homes; Hearing before the U.S. Senate
Committee on Finance March 17, 2021
Dear Chairman Wyden, Ranking Member Crapo, and Members of the
Committee:
The National Consumer Voice for Quality Long-Term Care, Community Legal
Services of Philadelphia, and the Michigan Elder Justice Initiative
would like to thank Chairman Wyden and Ranking Member Crapo for holding
this hearing on the devastating impact of the COVID-19 pandemic on
nursing home residents
Our organizations advocate for quality care, quality of life, and the
rights of nursing home residents and other long- term care consumers.
We appreciate the opportunity to share our input on this critical issue
with the Committee.
No group of Americans has suffered from COVID-19 more than nursing home
residents. Over 130,000 \1\ residents have died from COVID-19, while
over 1.1 million residents and staff have been infected.\2\ At the same
time, countless others have suffered from isolation and neglect. An
Associated Press article \3\ from November 2020 estimated that there
had been over 40,000 excess deaths in 2020 compared to 2019 that were
not attributable to COVID-19. That number is likely much higher now.
Adding to the suffering, one year after nursing homes were locked down,
tens of thousands of nursing home residents continue to have extremely
limited, if any, in-person contact with their families and loved ones.
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\1\ https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-
xpvg/.
\2\ Both numbers are an undercount. CMS did not require nursing
homes to start reporting data regarding COVID-19 cases and deaths until
May 8, 2020 and did not require facilities to report COVID-19 data back
to the beginning of the pandemic. Other totals, such as The New York
Times, are much higher. However, the Times total includes all long-term
care facilities, for instance, assisted living facilities, and not just
nursing homes.
\3\ https://apnews.com/article/nursing-homes-neglect-death-surge-
3b74a2202140c5a6b5cf05cdf0
ea4f32.
These numbers are even more tragic because much of this suffering and
death could have been prevented. Years of insufficient staffing and the
nursing home industry's focus on profits over residents, combined with
the slow and inadequate federal response to the pandemic in long-term
care facilities created a perfect storm resulting in tragedy. COVID-19
has also exposed the failures of nursing homes to care for and protect
residents adequately. Without significant policy changes, long-standing
problems will continue, future pandemics will be equally devastating,
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and residents will be the ones who suffer and die.
We urge Congress to:
Initiate an investigation into the devastating impact of COVID-
19 on nursing home residents.
Support nursing home staff by requiring minimum staffing
standards, training, and increased wages and benefits.
Require the rescission of all waivers of nursing home
regulations established during the Public Health Emergency.
Ensure access to COVID-19 vaccines for all residents and staff
who choose to be vaccinated.
Ensure protection from COVID-19 for residents and staff by
ensuring ongoing access to PPE and testing.
Fully restore visitation in nursing homes.
Reinstate standard and complaint surveys and strengthen
regulations and enforcement.
Require transparency and accountability around nursing home
ownership and finances.
Address disparities in care for racial and ethnic minorities.
Expand choice through the expansion of Medicaid Home and
Community Based Services.
Many of these recommendations will have the immediate effect of
preventing further harm from COVID-19 while also having the long-term
benefit of increasing the overall quality of care and preventing a
recurrence of the devastation wrought by COVID-19 in the future.
I. Investigate the Full Impact of the COVID-19 Pandemic on Residents
of Long-Term Care Facilities, Including the Disproportionate Impact on
People of Color
Before the pandemic, 82% of nursing homes in the United States had been
cited for an infection control violation, with 50% of those homes
having repeated problems.\4\ The deadly impact on nursing home
residents from infections has long been known. Infections have been a
leading cause of morbidity and mortality among nursing home residents,
with 1.6 million to 3.8 million infections per year before the
pandemic.\5\ Yet, many nursing homes were utterly unprepared to prevent
the spread of infectious disease among residents. In August 2020, five
months into the pandemic, former CMS Administrator Seema Verma noted
that nursing home inspections continued to find widespread failures in
basic infection control procedures, such as handwashing.\6\
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\4\ https://www.gao.gov/products/gao-20-576r.
\5\ Richards, C. Infections in residents of long-term care
facilities: An agenda for research. Report of an Expert Panel. 50 JAGS.
570-576 (2002).
\6\ https://skillednursingnews.com/2020/08/cms-targets-infection-
control-in-new-nursing-home-training-program/.
From the outset, the industry has asserted that since COVID-19 rates in
the community heightened the risk of spread in the facility, there was
little it could do to protect residents. This claim has been proven
inaccurate by numerous studies that show that similarly situated
nursing homes that invested in staffing and care quality did better
than homes that did not.\7\ Recently, the New York Attorney General
released a report \8\ finding that a facility's prior history of
inadequate staffing was more predictive of outcomes than other factors,
including its geographic location.
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\7\ Figueroa, J.F., Wadhere, R.K., Papanicolas, I., Riley, K.,
Zheng, J., Orav, E.J. and Jha, A.K.. Association of nursing home
ratings on health inspections, quality of care, and nurse staffing with
COVID-19 Cases. JAMA: (2020): August 10, E1-E2; He, M., Li, Y., and
Fang, F. Is there a link between nursing home reported quality and
COVID-19 cases? Evidence from California skilled nursing facilities.
JAMDA. 2020: 905-908; Li, Y., Tempkin-Greener, H., Shan, G. and Cai, X.
COVID-19 infections and deaths among Connecticut nursing home
residents: facility correlates. JAGS: June 18, 2020.
\8\ https://ag.ny.gov/sites/default/files/2021-
nursinghomesreport.pdf.
COVID-19 has had a disparate impact on nursing home residents of color.
Data shows that homes with large populations of Black and Latinx
residents were disproportionately affected compared to other homes.\9\
Congress must ensure that the causes of these disparities are
investigated and addressed.
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\9\ Li, Y., et, al, Racial and Ethnic Disparities in COVID-19
Infections and Deaths Across U.S. Nursing Homes, Journal of American
Geriatric Society, 2020 Nov., 68(11):2454-2461; NY Times, https://
www.nytimes.com/article/coronavirus-nursing-homes-racial-
disparity.html?action=click
&module=Well&pgtype=Homepage§ion=US%20News.
CMS was slow to require transparency of conditions in nursing homes as
a result of the pandemic. It was not until May 2020 that CMS required
all facilities to report data to the CDC about COVID infections,
deaths, etc., and it failed to require the reporting retroactively. As
a result, there is little data from the months before May, when tens of
thousands of residents contracted COVID-19 and died. At the same time,
CMS waived facility reporting of staffing data to the Payroll-Based
Journal and delayed reporting assessment data. Complete reporting is
essential to establish an accurate and complete picture of what
occurred during this time. It is vital to have this information to
learn from early failures and help ensure they do not recur. We urge
Congress to investigate the effect of COVID-19 on nursing home
residents thoroughly. Any investigation should include recommendations
to improve care quality and prevent a recurrence of the nursing homes
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crisis.
II. Support the Long-Term Care Workforce Through Minimum Staffing
Standards, Training, and Increased Wages and Benefits
Staffing
Since CMS began releasing weekly data in May 2020, on average, 19% of
nursing homes have reported a shortage of nurse aides, while 16%
reported a shortage in nurses.\10\ Over 554,000 nursing home staff have
been infected with COVID-19, and at least 1,625 have died.\11\ Many
workers have resigned due to fear of contracting COVID, family and
caregiving responsibilities that have increased during the pandemic, or
frustration due to untenable working conditions. These factors
exacerbated insufficient staffing levels that pre-dated the pandemic
and placed workers in impossible situations and residents at risk of
harm.
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\10\ https://data.cms.gov/stories/s/bkwz-xpvg.
\11\ Id.
The federal government does not require minimum staffing levels, and as
a result, inadequate staffing has long been a problem in nursing
facilities. Numerous studies have linked higher staffing levels to
better care.\12\ CMS's own study on appropriate staffing found a clear
association between nurse staffing levels and quality care.\13\
Insufficient staffing proved deadly during the pandemic, with studies
showing that facilities with higher staffing levels and ratings fared
better on controlling COVID-19 spread and resident outcomes than poorly
staffed homes.\14\
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\12\ Castle, N.G., Wagner, L.M., Ferguson, J.C., and Handler, S.M.
Nursing home deficiency citations for safety. J. Aging and Social
Policy, 2011; 23 (1):34-57; Castle, N.G. and Anderson, R.A. Caregiver
staffing in nursing homes and their influence on quality of care.
Medical Care, 2011:49(6):545-552; Schnelle, J.F., Simmons, S.F.,
Harrington, C., Cadogan, M., Garcia, E., and Bates-Jensen, B.
Relationship of nursing home staffing to quality of care? Health Serv
Res., 2004: 39 (2):225-250; Spector, W.D., Limcangco, R., Williams, C.,
Rhodes, W. and Hurd, D. Potentially avoidable hospitalizations for
elderly long-stay residents in nursing homes. Med Care, 2013: 51
(8):673-81.
\13\ Centers for Medicare and Medicaid Services, Abt Associates
Inc. Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes.
Report to Congress: Phase II Final. Volumes I-III. Baltimore, MD.
\14\ Li, et. al, 2020, ``COVID-19 Infections and Deaths Among
Connecticut Nursing Home Resident: Facility Correlates;'' Journal of
the American Geriatrics Society, Vol. 68, Issue 10, 2153-2162.
Before the pandemic, RN presence was directly related to quality care
and better outcomes for residents.\15\ It also proved to be predictive
of outcomes during the pandemic, as homes with total RN staffing levels
under the recommended minimum standard (.75 hours per resident day) had
a two times greater probability of having COVID-19 infections.\16\ Yet,
nursing homes are only required to have an RN present 8 hours daily.
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\15\ Dellefield, M.E., Castle, N.G., McGilton, K.S., and Spilsbury,
K. The relationship between registered nurses and nursing home quality:
An integrative review (2008-2014). Nurs Econ., 2015; 33(2):95-108,
116.b
\16\ Harrington, et. al., 2020, Nursing Staffing and Coronavirus
Infections in California Nursing Homes; Policy Politics and Nursing
Practice, 2020, Vol. 21(3) 174-86.
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Training
Early in the pandemic, the previous administration waived the
requirement that nurse aides meet training and certification
requirements \17\ during the Public Health Emergency. CMS claimed that
the waiver was necessary to address staff shortages. In reality, the
waiver resulted in Temporary Nurse Aides (TNAs) who were ill-equipped
to provide necessary care and services to residents and put the workers
and residents at increased risk of injury. TNAs who had not been
trained in proper infection control entered a medical setting where
protecting residents from infectious disease was paramount.
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\17\ https://www.cms.gov/files/document/summary-covid-19-emergency-
declaration-waivers.pdf.
To date, this waiver is still in place, and proposals exist at the
state and federal levels for waving the training and certification
requirements for these workers permanently. If the pandemic has taught
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us anything, it is that more training is needed, not less.
It is also unclear how many untrained and uncertified workers have
fallen under this waiver and how much training and supervision they
have had. In fact, it is doubtful whether CMS will be able to determine
the total number. It would be highly irresponsible to waive these
requirements without knowing how many staff, and in turn, residents
will be affected.
The current training requirements for CNAs are inadequate as well. CNAs
have more contact with residents than any other staff members. However,
federal training requirements for CNA certification are only 75 hours.
Increasing acuity and complexity of residents' needs, including higher
incidences of dementia, warrant a need for increased training
standards. In its report on the adequacy of the healthcare workforce
for older Americans (Retooling for an Aging America, 2008), the
National Academy of Medicine (formerly the Institute of Medicine)
recommends that ``federal requirements for the minimum training of
certified nursing assistants (CNAs) and home health aides should be
raised to at least 120 hours and should include demonstration of
competence in the care of older adults as a criterion for
certification'' (Recommendation 5-1).
Increased Wages and Benefits
A report \18\ released by LeadingAge, an organization representing non-
profit nursing homes, documented that almost half of nursing home care
workers earned less than a living wage, with nearly 57% relying on
public assistance. One study \19\ documented that nursing homes'
nursing staff turnover rate was roughly 100% annually, even before the
pandemic. The LeadingAge report states that increasing wages for
nursing home workers would reduce this turnover and significantly
improve residents' health outcomes. Increased wages are necessary to
attract and retain highly experienced and well-trained workers. On the
one hand, we cannot call our nursing home workers heroes, while on the
other, paying them wages that require them to rely on government
assistance.
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\18\ https://leadingage.org/sites/default/files/
Making%20Care%20Work%20Pay%20Report.pdf.
\19\ Gandhi, A., Yu, G., Grabowski, D. High Nursing Staff Turnover
in Nursing Homes Offers Important Quality Information, Health Affairs,
2021, Vol. 40, No, 3.
Further contributing to unsafe conditions for staff and residents, too
many facilities do not have a qualified infection preventionist to
support and implement infection prevention and control protocols
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necessary to sufficiently address the spread of COVID-19.
Lastly, understaffing is made worse by the failures of CMS to enforce
adequate staffing levels. A recent report \20\ by the Office of
Inspector General found that CMS should do more to strengthen oversight
of nursing home staffing.
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\20\ https://oig.hhs.gov/oei/reports/OEI-04-18-00451.pdf.
To better support the facility's staff and attract and retain
experienced and qualified workers that can increase positive health
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outcomes, Congress should urge CMS to:
End the Trump Administration's waiver of training requirements
for nurse aides and feeding assistants enacted in March 2020. Require
temporary nurse aides hired under this waiver to complete full training
and certification within a designated timeframe to continue working and
require nursing homes to identify and publicly report numbers of
Temporary Nurse Aides currently employed.
Increase initial nurse aide certification training requirements
from the current 75 hours to adequately prepare frontline aides for the
complex needs of the people they are hired to assist. Require
facilities to cover the cost of training.
In addition, Congress should pass legislation that:
Strengthens the direct care workforce by (a) increasing
compensation, including hazard pay (b) improving access to affordable
health insurance, paid family and medical leave, paid sick leave, and
affordable childcare.
Requires a minimum staffing standard of at least 4.1 hours per
resident day.
Requires 24-hour RN presence in all nursing homes.
Establishes a robust enforcement mechanism to ensure adequate
staffing levels.
III. Require the Rescission of all Waivers of Nursing Home Regulations
Established Under the Public Health Emergency
In addition to the training and certification waiver, the previous
administration issued multiple waivers of standards and requirements
for healthcare providers, including nursing homes, through the use of
1135 waivers.\21\ These waivers included waiving notice of transfer or
discharge and facility reporting requirements, including resident
assessment information and staffing information.
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\21\ https://www.cms.gov/files/document/summary-covid-19-emergency-
declaration-waivers.pdf.
The waiver allowing facilities not to report resident assessment
information and staffing information has been rescinded. However, CMS
has publicly stated that it will not require facilities to provide the
staffing information for the period that reporting was waived, even
though it is readily accessible to nursing homes. When CMS made this
decision, the period for which the reporting waiver applied had been
the deadliest for nursing home residents. If we are to understand what
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happened during the pandemic, facilities must provide this information.
Waivers must not continue indefinitely without evaluation to assess
whether they continue to be needed or effective. Many of the waivers
referred to in this document remove essential resident rights
articulated in law and regulation.
Congress should urge CMS to:
Rescind the waivers of nursing facility requirements that permit
waivers of notice for transfer or discharge due to cohorting and nurse
aide training.
Require facilities to report data on staffing from January 1st-
May 2020. All of this data is already in the possession of nursing
homes and is critical for analyzing what happened during that time and
what we can do to prevent it in the future.
IV. Ensure Access to COVID-19 Vaccines for All Residents and Staff Who
Choose to be Vaccinated
The discovery and release of highly effective and safe COVID-19
vaccines has offered promise to residents and staff. Since residents
and staff began receiving vaccinations, COVID-19 case numbers and
deaths have plummeted. Yet not all residents have equal access to the
vaccine in nursing homes.
In all states but West Virginia, the CDC partnered with outside
pharmacies to conduct clinics at nursing homes to have residents and
staff vaccinated. These pharmacies have adopted a policy of only
visiting nursing homes three times to vaccinate residents. As a result,
residents who entered the facility after the second clinic have just
received one dose of the vaccination. Others who were admitted after
the third clinic have not received a vaccine at all. In some states,
plans have not yet been established to ensure continued access to
vaccines, and in some cases, facilities are requiring residents to
obtain the vaccination themselves. This policy creates an unacceptable
burden on residents and families to ensure they become fully
vaccinated. For many residents, this task will be impossible and will
result in them going without the protection of a vaccine.
New residents and staff continue entering nursing homes and should be
offered the vaccine. Currently, there is no policy from the federal
government setting forth a plan for ensuring these residents can become
fully vaccinated.
Early reports \22\ stated nursing home staff were refusing vaccination
at a rate as high as 60%. This high refusal rate has been attributed
mainly to distrust of the vaccine and a lack of information accessible
to staff.\23\ CMS and CDC must continue efforts to provide staff with
information on vaccines that address staff concerns and help increase
vaccination rates among staff.
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\22\ https://www.cnbc.com/2021/02/09/covid-vaccine-60percent-of-
nursing-home-staff-refused-shots-walgreens-exec-says.html.
\23\ https://www.health.harvard.edu/blog/why-wont-some-health-care-
workers-get-vaccinated-2021021721967.
It is also vitally important for current and future residents and their
families to have access to information that shows how many residents
and staff have been vaccinated in each facility. This information will
be essential for residents to make informed decisions on their care and
where they want to reside. Although the CDC is releasing total numbers
of staff and residents who have been vaccinated, it is not at the
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facility level.
To ensure all residents and staff have access to the COVID-19
vaccination, Congress should:
Require federal, state, and local coordination for ensuring
ongoing access to vaccines for all residents and staff of long-term
care facilities.
Require nursing homes to report the number and percentage of
their residents and workers who have been vaccinated and disclose that
information to residents, families, staff, the LTCOP, the State Survey
Agency, CMS and CDC. Vaccination rates in nursing homes should be
reported to the CDC and shared publicly on Nursing Home Compare (Care
Compare).
V. Ensure Protection from COVID-19 for Residents and Staff by Ensuring
Ongoing Access to PPE and Testing
As with many health facilities, nursing homes have struggled to obtain
and maintain adequate supplies of high-quality personal protective
equipment (PPE). Many nursing homes continue to report less than one-
week supplies of masks, gowns, and gloves.\24\ Additionally, ensuring
facilities have sufficient access to accurate COVID-19 testing will be
essential in helping prevent outbreaks. To ensure all facilities have
adequate PPE and testing, Congress should:
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\24\ For instance, for the week ending February 14, 2001, 5% of
nursing homes reported they had less than a one week supply of N-95
masks, https://data.cms.gov/stories/s/bkwz-xpvg.
Establish an effective supply chain for the distribution of PPE
to long-term care facilities, and ensure funding for sufficient, usable
PPE to supply nursing home staff, visitors, surveyors, and LTC
ombudsmen.
Require all facilities to have a 30-day supply of PPE on hand.
Provide funding and hold facilities accountable for paying for
accurate point-of-care testing with rapid turnaround of results for
staff, residents, and their families who visit.
VI. Fully Restore Visitation in Nursing Homes
On March 13, 2020, CMS issued an order \25\ prohibiting anyone other
than essential health care workers from entering nursing homes. As a
result, residents were isolated from their families and subject to
neglect and harm due to inadequate staffing. As time passed, the harm
from isolation and neglect began to take a toll on residents' health
and well-being.\26\ These problems mainly went unseen, as facility
surveyors, families, and long-term care ombudsmen were restricted from
entering facilities. Residents could no longer rely on their loved ones
to draw attention to health declines or inadequate care. As some
facilities re-opened their doors to visitation, many family members
discovered their loved ones had experienced a devastating decline,
including significant weight loss, cognitive decline, emotional
distress, and extremely poor hygiene.\27\
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\25\ CMS, QSO-20-14-NH, updated by QSO-20-39-NH (Sept 17, 2020).
\26\ https://apnews.com/article/nursing-homes-neglect-death-surge-
3b74a2202140c5a6b5cf05cd
f0ea4f32.
\27\ https://theconsumervoice.org/uploads/files/issues/
Devasting_Effect_of_Lockdowns_on_Res
idents_of_LTC_Facilities.pdf.
On March 10, 2021, CMS issued new visitation guidance \28\ that relaxed
some of the visitation restrictions. While a step in the right
direction, the guidance does not go far enough, however, to protect
residents from the effects of isolation and neglect. The guidance
language allows facilities significant discretion when determining the
length and frequency of visits, including for compassionate care. CMS
must require facilities to permit visits based on the needs of each
resident and enforce those requirements.
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\28\ CMS, QSO=20-39-NH.
Further, residents continue to need access to telecommunications
devices and Internet services in order to communicate with family and
friends who are unable to visit in person. Such access is necessary for
supporting many residents who suffer from isolation. Despite efforts to
increase access during the pandemic, many facilities do not have
devices that can be used by residents who do not have their own, and
there are facilities that refuse to allow a resident to connect their
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personal device to the facility's Internet connection.
To help protect residents, Congress should:
Allow every resident to designate an essential support person
(ESP). The ESP must be allowed unrestricted access to residents to
provide physical and emotional support and assistance in meeting
residents' needs. ESPs should be treated as employees of the facility
for infection control purposes, including routine COVID-19 testing and
the wearing of PPE (cost to be borne by the facility).
Urge CMS to modify its visitation guidance to require facilities
to permit visits based on the needs of each resident and, until full
visitation rights are restored, ensure that visits are no less than one
hour weekly.
Require CMS to enforce visitation guidance.
Pass legislation that provides access to telecommunications
devices and the Internet for all residents.
VII. Reinstate Annual Recertification and Complaint Surveys and
Strengthen Regulations and Enforcement
Recertification and Complaint Surveys
At the same time visitation bans were instituted, the previous
administration suspended surveys and enforcement except in very limited
situations. CMS directed State Survey Agencies to prioritize the most
egregious complaints (triaged as immediate jeopardy) and implemented a
new type of survey focused on infection prevention and control
requirements,\29\ to the exclusion of all other issues. As a result,
state survey agencies did not conduct complaint investigations (except
for immediate jeopardy) or annual surveys for months. Complaints of
rights violations, neglect, eviction, and similar serious issues were
ignored to the residents' great detriment.
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\29\ CMS, QSO-20-20-All.
While CMS issued guidance in September 2020 to reinstate survey
activities, not all states have. As of the date of this hearing,
California, Ohio, and Tennessee, for example, still have not begun
completing annual recertification surveys. California is still only
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investigating IJ-level complaints.
Congress should urge CMS to ensure that all states are conducting
annual recertification surveys and investigating all complaints.
Regulations
In 2017 CMS issued final federal rules for nursing homes that rolled
back the ban on pre-dispute arbitration and in 2019 issued proposed
rules to further roll back the revised nursing home rules published in
2016. These proposed rules would provide fewer protections for
residents and less accountability for nursing facilities by, among
other things, weakening standards relating to infection prevention, use
of antipsychotic medications, and responding to resident and family
grievances.
Congress should:
Urge CMS to rescind its 2019 proposed rules to ensure that
nursing home residents are not stripped of these necessary protections.
Pass legislation banning forced arbitration agreements in
nursing homes.
Urge CMS to reinstate the regulation banning nursing home
arbitration agreements.
Enforcement
Prior to the pandemic, insufficient enforcement of regulations long
plagued nursing home care. Deficiencies were under-cited and often did
not \30\ identify serious problems. Enforcement actions are also not
sufficiently meaningful to bring about lasting change, as evidenced by
a 2019 \31\ OIG report that found that 31 percent of nursing homes had
a deficiency (violation) cited at least five times during 2013-2017,
and \32\ a study which determined that 42 percent of deficiencies were
given for chronic or repeated deficiencies in a 3-year period.
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\30\ Office of the Inspector General (OIG). States continued to
fall short in meeting required timeframes for investigating nursing
home complaints: 2016-2018. Data Brief. Washington, DC: OIG OEI-01-19-
00421. September 2020.
\31\ Office of the Inspector General (OIG). Trends in deficiencies
at nursing homes show that improvements are needed to ensure the health
and safety of residents. HHS Data Brief. April 2019. 09-18-02010.
\32\ A Long Term Care Community Coalition. Issue Alert. Chronic
deficiencies in care: The persistence of recurring failures to meet
minimum safety and dignity standards in U.S. nursing homes. LTCCC,
February 2017. http://nursinghome411.org/nursing-homes-with-chronic-
deficiencies/.
Enforcement was further weakened by actions taken under the previous
administration. In 2017, CMS revised its enforcement policy to change
the default method of assessing civil money penalties for past non-
compliance from the imposition of ``per-day'' fines to ``per-instance''
fines. This change removes any incentive for facilities to identify and
correct non-compliance as early as possible, resulting in residents
subjected to potentially harmful non-compliance for an extended period.
We believe this revision was made in violation of proper administrative
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procedures.
These failures of enforcement certainly contributed to the crisis in
nursing homes during the pandemic. Repeated and long-standing
violations are the result of facilities facing little pecuniary
punishment. As noted above, 8 out of 10 facilities had infection
control violations before the pandemic, with half of those having
repeated problems. Until CMS adopts a rigorous and consistent
enforcement strategy, the issues that led to the devastation in nursing
homes will continue.
Congress should:
Require CMS to ensure that comprehensive and complaint surveys
have been fully restarted in all states.
Direct CMS to withdraw the proposed rules on nursing facility
Requirements of Participation published Federal Register, Vol. 84, No.
138, July 18, 2019, 34737.
Strengthen federal and state enforcement by requiring pre-
established per-day penalties and utilizing denials of payment for
resident admissions for non-compliance with specific requirements, such
as staffing, transfer/discharge, life safety, emergency preparedness,
and infection control.
Instruct CMS to rescind the Trump Administration directive,
``Revision of Civil Money Penalty (CMP) Policies and CMP Analytic
Tool'' (S&C 17-37-NH), which instructed State Survey Agency Directors
and CMS Regional Offices that ``per-instance'' CMPs would be imposed
for past non-compliance, conflicting with the enforcement provisions in
the Social Security Act that provide for the imposition of CMPS for
``each day of non-compliance.''
VIII. Require Transparency and Accountability Around Nursing Home
Ownership and Finances
For years, the nursing home industry has been plagued by poor care
brought on by the purchase of homes by corporations and Private Equity
Investment (PE) firms with little or no experience in healthcare or
with a long history of providing substandard care. A study released in
February 2021 estimated that PE ownership of a nursing home increases
the mortality of Medicare residents by 10%, results in declines in many
measures of well-being for residents and increases taxpayer spending
per resident by 11%.\33\ A recent report in the Washington Post
revealed that even during the pandemic, investment groups with a long
track record of owning homes that provide poor quality care were
allowed to buy over 20 homes and that care suffered.\34\
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\33\ https://www.nber.org/system/files/working_papers/w28474/
w28474.pdf.
\34\ https://www.washingtonpost.com/local/portopiccolo-nursing-
homes-maryland/2020/12/21
/a1ffb2a6-292b-11eb-9b14-ad872157ebc9_story.html.
Corporate and PE firms have slashed resources, including cutting staff
and supplies.\35\ It is common practice for them to pay related third
parties, such as vendors, management companies, and others, for
services as a means of funneling money to themselves.\36\ Yet, there is
no system to audit the use of federal funds and determine whether they
go to profits or resident care.
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\35\ Harrington, C., Olney, B., Carrillo, H., Kang, T. Nurse
staffing and deficiencies in the largest for-profit chains and chains
owned by private equity companies. Health Serv Res., 2012; 47(1 pt.
I):106-128.
\36\ Harrington, C., Ross, L., Kang, T. Hidden ownership, hidden
profits, and poor quality of nursing home care: A case study.
International Journal of Health Services, 2015;45 (4): 779-800.
To improve the quality of care in nursing homes and to ensure the
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appropriate use of taxpayer money, Congress should pass legislation:
Mandating audits to determine how facilities spend taxpayer
money.
Setting limits on administrative costs and profits for all
payors.
Requiring CMS to establish federal regulations to specify the
minimum criteria for purchasing or managing any nursing home.
IX. Address Disparities in Care for Racial and Ethnic Minorities
All residents are entitled to quality care and services, access to
justice, and protection from discrimination. Black and Latinx nursing
home residents have been disproportionately affected by COVID-19.\37\
Research has shown the disparities in care experienced by individuals
based on race, ethnicity, and socioeconomic status have become
pronounced during the COVID pandemic.\38\ This research points to long-
standing racial inequities that pre-date COVID-19. Due to
discriminatory lending policies, housing segregation, greater reliance
on Medicaid, and inequitable health-
care access, marginalized populations are more likely to reside in
racially and ethnically identifiable nursing homes that provide poorer
care. Data gathering practices and targeted interventions must be
developed to ensure that residents' care needs are met.
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\37\ Li, Y., Cen, X., Cai, X., and Temkin-Greener, H. Racial and
ethnic disparities in COVID-19 infections and deaths across U.S.
Nursing Homes. JAGS, 2020:1-8 DPO:10:1111/jgs.16847.
\38\ Gebeloff, R., Ivory, D., Richtel, M., Smith M, Yourish K.,
Dance, S., Fortier, J., Yu, E., and Parker, M. (2020). Striking racial
divide: How COVID-19 has hit nursing homes. The New York Times, May 21,
https://www.nytimes.com/article/coronavirus-nursing-homes-
racialdisparity.
html?action=click&module=Well&pgtype=Homepage§ion=US%20News.
CMS policies make addressing disparities in care difficult. Although
CMS collects data on race and ethnicity, it does not release this data
to the public, which has created a gap in knowledge regarding how
minority groups are treated in nursing homes. However, COVID-19 has
laid bare that residents of color receive inferior quality of care when
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compared with others.
We urge Congress to:
Require CMS to collect and report nursing home resident
demographic data specific to race and ethnicity, source of payment, and
ownership.
Require CMS to require facilities to report racial demographic
data as part of the weekly data facilities report to the CDC.
Make CMS race and ethnicity data publicly available dating back
to the beginning of the pandemic. Policymakers, government agencies,
advocates, providers, and researchers need this information to identify
disparities in care and to develop enforceable public policies to
ensure equitable care for all residents.
Investigate and address the disparities in care and access to
services for racial and ethnic minorities, including disparate care and
outcomes in nursing homes under common ownership and operation,
Medicare and Medicaid policies that allow or promote discrimination
based source of payment, and other factors that result in disparate
placement in poor-performing, racially identifiable nursing homes, such
as hospital discharges.
X. Expand Choice Through Expansion of Medicaid Home and Community
Based Services
For many older adults with limited income and resources, needing
assistance with activities of daily living means going to a nursing
home. However, during the pandemic, many older adults chose to remain
home without sufficient supports to avoid the risk of being infected
with COVID-19 in a nursing home. While the implementation of Medicaid
waivers has improved access to home and community-based services (HCBS)
for these individuals, HCBS is not a required benefit under Medicaid,
and for those states where waivers exist, there often are limits on
coverage, limited availability of service providers and affordable
housing, and long waiting lists. The devastating effect of COVID-19 on
people living in congregate settings has only highlighted the need to
make HCBS a required benefit. Increased access to HCBS would likely
have saved lives during the pandemic.
To allow individuals who could successfully remain in or transition
back to their homes or community-based settings instead of entering or
staying in a nursing home, we urge Congress to:
Make HCBS a required benefit under Medicaid and allow coverage
of housing-related services and retroactive coverage for HCBS services.
Permanently reauthorize the Money Follows the Person program,
which has helped older adults and persons with disabilities transition
from institutions into the community.
Direct resources for more low-income housing and residential
care.
The pandemic's tragic impact on residents and staff of nursing home
residents was years in the making. Many of the recommendations in this
statement have been made by advocates for years, in part because it was
foreseeable that a virus like COVID-19 would devastate nursing homes.
We call on Congress to act now and take decisive steps to not only
prevent the next crisis, but to increases the quality of care in
nursing homes for current and future generations.
Sincerely,
The National Consumer Voice for Quality Long-Term Care
Community Legal Services of Philadelphia
Michigan Elder Justice Initiative
______
Statement Submitted by Mary Nichols, Texas Caregivers for Compromise
March 13, 2021 was one year since families were declared non-essential
and prevented from freely visiting loved ones in long-term care
facilities. CMS issued new guidance on March 10, 2021 that allows
expanded visitation but not only are most nursing homes still not in
compliance, but the guidelines do not apply to assisted living
facilities, group homes, intermediate care facilities and group homes
that do not received Medicaid and Medicare funding so those facilities
are still largely autonomous when it comes to regulating visitation.
Families must learn complex guidelines in order to argue to be admitted
to facilities or obtain assistance from an ombudsmen. This is
disproportionately skewed against lower income populations who work
multiple jobs and lack the luxury of being full-time advocates,
populations with language barriers, and those populations without
higher levels of education who struggle to decipher technical legalese
and analyze these complicated regulations against the restrictions
being given to them by their loved one's facility.
The severe weight loss, rapid cognitive decline, and extreme
despondency in residents from COVID-19 protocols continue to result in
loss of both life and quality of life. The mental health crisis taking
place among residents, families, and long-term care staff members
cannot be overstated as the intense pressures on people affected by
guideline enforcement increase daily. For a full year, residents have
felt abandoned and forgotten, life-long spouses have been separated,
adult children with cognitive disorders have not seen a parent or
sibling, dementia and Alzheimer's residents have lost memory of their
loved ones, people have died alone, and families have lost what time
remained with their loved ones who passed away in this last year.
CMS GUIDANCE IS MISUSED. Guidance put in place by CMS on September 17,
2020 and March 20, 2021 is widely misunderstood by facilities and the
visitation provisions within them have neither been acknowledged nor
implemented in a great many facilities in a majority of states.
Commonly, facilities point to CMS guidelines as the reason they cannot
allow any form of visitation. This is false. Meanwhile, recourse by
state health authorities is absent and there is no reason to anticipate
that facilities who ignore current visitation standards will follow
future or amended rules.
ESSENTIAL CAREGIVERS ARE NOT A PERMANENT SOLUTION. Many states are
adopting essential caregiver provisions that allow one or two family
members access to care for a resident for a few minutes or an hour or
two a week. Essential caregivers are a temporary solution for
visitation as they only allow a small increment of restoration of
resident rights. As we see many states beginning to adopt programs
similar to the Texas and Florida programs, our concern is that the
perception by our lawmakers will be that this is an acceptable
permanent alternative to visitation in long-term care facilities when,
instead, it is an emergency answer to be used as a last resort.
ADA VIOLATIONS. Current prohibition of visitation has resulted in
widespread and readily accepted violation of the Americans with
Disabilities Act.
UNEQUAL FAMILY ACCESS. Those residents who are cognizantly
healthy enough to use telephones, virtual visits and talk
through closed windows have far more access to family than
those bed-bound, deaf, blind, and intellectually disabled
residents as well as residents with advanced dementia and
Alzheimer's who are incapable of seeing virtual technology as
anything other than white noise, are bed-bound and unable to go
to a window, or become agitated and harm themselves when they
don't understand why a relative remains on the other side of
glass. Blind adults who depend on tactile communication are
eliminated from these visits, deaf adults are restricted by
small screens and windows are often not even wheelchair
accessible.
UNEQUAL PROTECTION FROM ABUSE AND NEGLECT. Intellectually
disabled adults and residents with dementia or Alzheimer's have
unequal protection from abuse and neglect as those residents
who are able to push a call-button or phone a relative. Outside
visitors, clergy, family, powers of attorney, hospice workers,
ombudsmen, and legal guardians are the extra eyes that assess a
resident's environment and welfare and affect change should
there be an issue or deficiency. The absence of those eyes
removes that protection from people incapable of calling for a
tray because the lunch cart missed their room, asking for a
shower, reporting a bedsore, or complaining about soiled
clothing. They have also lost those eyes that are familiar
enough to notice the subtle differences in the health or
behavior of the resident that staff members--frequently
temporary substitutes--might miss. This was one of the major
purposes of the 1987 Nursing Home Reform Act.
RESULTS OF FACILITY AUTONOMY. Facilities have had twelve months of
authority over decisions related to and rights of residents in long-
term care facilities. While they must have ability to make
administrative choices that best suit their facility's needs, these
choices have crossed over into decisions that:
Deny rights of residents guaranteed in state and federal law;
Make care decisions without resident and/or family input;
Circumvent guidelines put in place by Texas Health and Human
Services;
Circumvent Centers for Medicaid and Medicare Services
guidelines; and
Ignore recommendations of the CDC regarding discontinuation of
transmission based precautions for patients recovering from COVID-19
Facilities will not release this authority without argument and
resistance as the involvement of family members is often no longer
welcome but considered interference. While CMS guidelines do not apply
to all facilities, the ones that they do apply to often either do not
know the guidelines, do not understand the guidelines, or simply choose
not to follow the guidelines. The issues rising from those facilities
are many and egregious:
Refusing essential caregivers in states that allow them;
Not allowing hospice workers for a year;
Denying end-of-life visits;
Denying compassionate care visits;
Not following CDC recommendations re: discontinuation of
transmission-based precautions when a resident has recovered from
COVID-19 and isolating asymptomatic residents 24 to 35 days instead of
10;
Denying closed window visits;
Not allowing a resident to use his/her own property;
Making residents remain in their room, refusing communal dining,
and not allowing outdoor recreation, walks, or fresh air;
Prohibiting residents from opening or receiving mail;
Requiring a family to use the hospice company of the facility's
choice;
Refusing indoor plexiglass visitation;
Making resident care decisions without consulting legal
guardians, family, or Medical POAs;
Not allowing resident to participate in religious activity;
Not holding required care plan meetings with family members;
Denying resident a right to refuse a treatment; and
Denying ability to report abuse or neglect by refusing to allow
use of facility telephones
ONE YEAR IS THE REMAINDER OF A LIFETIME. The life expectancy of a
resident once he or she moves into long-term care is six months to two
years depending on which statistics you believe, the health of the
resident and the type of care required. The restrictions will have been
in place a year on March 13, 2021. That is the remainder of many
people's lifetimes.
POST-VACCINE VISITATION. New CMS guidance discriminates residents based
on whether they choose or decline the vaccine. There is much vaccine
reluctance at this time among many minority populations and this
regulation makes visitation rights disproportionately skewed against
those minorities. Residents in a county with 10% or more positivity who
have not received the vaccine are denied visitation. Not only is this a
disguised mandate of an emergency use vaccine but it makes a resident's
rights dependent on the choices of everyone else in the county to mask,
social distance, practice infection control, or receive the vaccine.
Nobody's statutory and federal rights should be dependent on the choice
somebody else makes.
DANGEROUS PRECEDENT. COVID-19 was an unprecedented crisis in our
country. But the unprecedented has now become precedented and we have
set a dangerous one. Imagine a war, emergency, crisis, or pandemic in
the future that disproportionately affects children under a certain age
or people of a certain genetic background or race. Would this country
stand for stripping them of their rights for their own good for over a
year? As ridiculous as that sounds, could we have imagined eighteen
months ago that residents in long-term care facilities would be
restricted from visitation and all those rights in the 1987 Nursing
Home Reform Act for a year? It's time that we agree that in the United
States of America the rights of no population should ever again end the
moment a pandemic begins.
______
Oregon Health and Science University
3181 S.W. Sam Jackson Park Rd.
Portland, OR 97239
www.ohsu.edu
Statement of Dr. Emily Morgan, Assistant Professor of Internal Medicine
and Geriatrics, Oregon Health and Science University; Medical Director,
Mirabella Skilled and Long Term Care
Chairman Wyden, Ranking Member Crapo, and Members of the Committee:
We are pleased to submit this statement for the record to offer
feedback on the Department of Health and Human Services Centers for
Medicare & Medicaid Services' (CMS) memorandum on Nursing Home
Visitation during the COVID-19 Public Health Emergency published on
March 10, 2021. We greatly appreciate the continued efforts of CMS to
ensure the health and safety of our vulnerable nursing home population
and we wholeheartedly agree with CMS' commitment to ending the social
isolation faced by many nursing home residents during this pandemic.
However, we feel it is important that we voice our concern regarding
how these changes are implemented, with the shared goals of reducing
the burden of isolation and keeping our most vulnerable population
protected.
We are concerned that the emphasis placed on allowing indoor visitation
``at all times and for all residents'' will unduly place residents and
facility staff at increased risk without additional limitations in
place. We ask that CMS consider adding an exception that clearly states
that indoor visitation will not be permitted when a facility cannot
safely ensure appropriate physical distancing and oversight during
visitation. We are concerned that facilities overwhelmed with visitors
will not have the available staffing needed to ensure safety protocols
are being appropriately followed, while at the same time delivering
adequate care to residents.
We would also like CMS to consider changing the use of 10% county test
positivity rate as an exception scenario for allowing un-restricted
indoor visitation. Test positivity is a crude measure of transmission
risk, but most would consider a rate of >10% as indicative of
widespread and un-controlled transmission in the community. Happily,
many counties in Oregon as well as other states have not seen
positivity rates this high even during the peak of the pandemic. We
believe that protecting the safety of residents and staff would best be
served by continued limits on visitation unless the local risk of
disease is low, for example, <5%. Also, since test positivity rates may
be highly dependent on access to testing, consideration should be given
to including other metrics, such as the rate of new cases/per 100, 000
population over the preceding 14 days (incidence rate) to determine
restrictions on visitation. (See https://coronavirus.oregon.gov/Pages/
living-with-covid-19.aspx#current
risklevelbycountyma for an example of how incidence rates and test
positivity may be combined as indicators of COVID-19 spread in the
community). In our opinion, restriction of indoor visitation should be
allowed unless local disease transmission has been minimized.
Lastly, we are concerned about the CDC's Updated Healthcare Infection
Prevention and Control Recommendations in Response to COVID-19
Vaccination, published March 10, 2021 which states ``quarantine is no
longer recommended for residents who are being admitted to a post-acute
care facility if they are fully vaccinated and have not had prolonged
close contact with someone with SARS-coV-2 infection in the prior 14
days. The potential for recent SARS-CoV-2 exposure of patients who are
being newly admitted to nursing homes cannot always be accurately
determined, whether they are being admitted from an acute care hospital
or the community. Risk of exposure may be highly variable depending on
community rates and/or the quality of infection control practices at
the referring care facility. In addition, we know that vaccination is
not 100% effective in preventing SARS-CoV-2 infections, and the level
of protection provided against emerging virulent and highly
communicable genetic variants of concern is still uncertain. Although
the risk of COVID-19 disease among fully vaccinated patients may be
relatively low, the consequences of transmission within a nursing home
can be devastating. Quarantine of newly admitted nursing home residents
remains an important tool in outbreak prevention. While quarantine is
isolating, perhaps the best way to address this would be to recommend
quarantine for 7 days accompanied by testing to shorten the quarantine
period while maintaining this important safeguard.
We are thankful for the continued efforts of CMS and the CDC to
prioritize the health and wellness of our nursing home residents and
staff. It is with much excitement that we look forward to increased
visitation and decreased isolation for our residents that have suffered
so much in this last year. We appreciate the Committee's interest in
this issue and CMS' willingness to consider the feedback we offer here
and move to implement safe visitation and transitions of care policies
that continue to offer the highest degree of protection to our nursing
home communities.
With Many Kind Regards,
Emily Morgan, M.D.
Cc: Liz Richter, Acting Administrator, Centers for Medicare and
Medicaid Services
______
Letter Submitted by Carolyn Piper
Thank you for the opportunity to add my statement to the record of this
hearing. I am a 70 year old daughter, living in NV, of parents residing
in long-term care in PA. Unfortunately they are in two separate
``facilities'' in a continuing care conglomerate, since they need
different levels of care. My mother requires skilled care, on the
second floor of her building. My father requires assisted living care,
residing on the ground floor of the same building. Thus their dwellings
are under separate licenses, making my father the dreaded ``Visitor''
this past year.
From the time of my mother's stroke almost 4 years ago, I was traveling
to PA every month for the first year, then every 6-8 weeks after that
until Feb 2020. My mother has no language and no mobility, totally
helpless and dependent on others. Every single communication is done by
the same hand wave, and we spent hours trying to determine what she
wanted or needed. The frequency of my visits was to ensure that my
parents' needs were being met, to participate in planning meetings, and
to advocate for unmet needs. I was also able to provide extra direct
care and stimulation to my mother for participation in some activities
(she declined everything that staff offered), general stimulation and
conversation, long walks outside in her wheelchair (which staff never
had time to do and which was the only recreation that was meaningful to
her in any way) and eating assistance because we discovered through
diligent trial and error what she liked to eat and how it could be
prepared on her tray to help her to be the most independent in feeding
herself as possible. I was her voice, because she no longer had one.
Prior to COVID, I worried about the long hours that she was languishing
alone in her bed for 20 hours every day. But I knew that between my
visits, my 2 brothers and sister, and my nephew were visiting sometimes
multiple times a week. They provided all of these same things.
And then with no warning, no one was allowed back in. My mother, who
does not read a newspaper, and does not watch TV, and whose brain is
severely damaged from her massive stroke, only knew that no one was
coming anymore to take her outside, or wheelchair walks through the
building, or fix her meal tray, or brush her hair, or brush her teeth,
or clean her dirty face, or wipe the scum and smell from between her
clenched fingers, or make sure staff saw the crust and redness on her
inner elbow or under her breast or on her elbow, and then treated it
properly. She surely must have felt abandoned, alone, depressed,
despondent. She had no concept of virus, or mitigation, or pandemic.
Not even my father was allowed back in. And what we thought would be a
two week separation turned into a year. My brother and nephew got a
couple ``window visits,'' but my hard of hearing mother could not hear
them through the glass door and masks. She did not comprehend why they
did not come in. Then there were Facetime calls, which she did not even
understand before her stroke, and with no communication on her part,
all we could do was to ``eyeball'' her and try to explain in words she
probably did not remotely comprehend why we were no longer coming. My
sister had one compassionate visit with her in her room during the
year, but could not go at lunch to provide feeding help, could not walk
her anywhere (not allowed out of the room), could not go on the weekend
(not enough staff) and was allowed two visits and done. Just an
arbitrary rule from what we could understand. I was ``not allowed'' in
for a year, because the PA governor issued a prolonged 14 quarantine
stipulation for out of state travelers into PA, and my finances did not
allow for two weeks in PA and then two visits with my parents.
In addition to my own personal story, I am a member of a national
Facebook group called Caregivers for Compromise- Because Isolation
Kills too. There are over 14,000 members. The PA chapter that I belong
to has over 600 members. So, over the last several months, I have read
hundreds of tragic stories about long term care residents and their
families suffering through this often total and prolonged isolation, as
they lived and too often died alone.
Here is what I have learned this past year, and what I would like to
share about my perspective on this tragedy.
I shudder to think what would have happened to my mother without family
there to support her and encourage her and advocate for her and
sometimes even fight for her 4 years ago when she first entered the
nursing home. Her care was standard, but I know without any doubt that
her family was the critical element to her living. We supplemented
direct care and our presence was her medicine. We saw things that staff
missed and interpreted her hand waves because in their busy every day
work life, there was not time to spend hours to figure out what she
wanted or needed. We helped to relieve her anxiety because she no
longer spoke but we knew she was aware and afraid and helpless. We were
there to help her match cards, and copy letters, and try to speak, and
exercise her arms and legs. Having lost all mobility on her own, we
walked her miles in her wheelchair. We were her lifeline and her
connection to the world outside of her 12 by 12 room.
How many thousands of new residents have entered long-term care
facilities this past year with no one to support them or encourage them
or advocate for them, or report neglect that they saw? How many were
unnecessarily medicated because they seem depressed, or anxious, or
starting having ``behaviors''? How much was all of this due singularly
to isolation? How many died with no one by their side, and no good
byes? Have you seen all the pictures that have been posted of
accelerated decline? The ``unintended consequence'' to the lockdown? Or
as residents would say, the lock-up? Residents suffered and families
suffered and there will never be closure for them.
We learned that facilities earned ``rewards'' from the federal
government for reducing COVID cases. On the surface, that mitigation
success seems to be a very good thing. But how did this very monetary
award incentivize keeping families out? How were those funds used to
enhance ongoing and meaningful connections with
In May 2020, the Centers for Medicare and Medicaid Services (CMS)
issued some visitation guidelines but I don't think families ever
grasped very well that these existed and how to get them enforced. By
the time of the new guidelines in Sept. 2020, we were more educated and
sharing information with each other. Still, the guidelines were vague
and up for much interpretation.
Just to summarize the great disparity, and with all other things being
equal related to outbreak status and county positivity rate:
Some facilities arranged compassionate care visits. Others
absolutely did not.
Some facilities eventually worked with families to a compromise.
Others stood with a firm no.
Some facilities told families, well if we let you in, we will
have to let others in. So they still said no. And yet every single
resident should have been entitled to a compassionate visit after 10
months of being confined to their room and many times not even
understanding why their family had abandoned them to be left alone.
Some allowed daily up to two hours. Even twice daily. Some
allowed twice a week, because they said CMS said that these visits
should ``not be routine.''
Some allowed these visits at meal times (so the family member
could actually support a need.) Others said absolutely not at meal time
(even in a resident's private room) because the resident would have
their mask off. But really, families could wear masks while they helped
with a meal, just like staff could.
Some required the family find their own COVID test. Others (a
very few) would provide the test on site prior to the visit. Where were
all the tests that the Governors had received? Wasn't finding ways to
safely reunite families a priority?
Some required testing every three days, some twice a week, even
when staff were tested weekly or monthly. That was a monumental
challenge and hardship for family members who were trying to stretch
the truth so they could schedule free tests at CVS. Or it's out of
pocket at a private lab, up to $125.
Some continued Compassionate visits with county positivity over
10%. Others shut down all but perhaps a single end of life visit when
positivity exceeded 10%. Some even restricted all Compassionate visits
for up to 4 weeks based on this positivity rate, when there had been
only one or two (``reported'') asymptomatic positive non-resident cases
and no one in the building was in isolation. The PA Division of Nursing
Facilities told me, and the CMS document from Sept 17 stated, that CC
visits are to supersede county positivity. My correspondence to a CMS
Triage email verified this. But who are we to argue with facilities
when we have no backing because there was just enough vagueness in the
guidance that they could "twist it," or perhaps merely misunderstand
it?
What was most frustrating to us as family members, was that all these
facilities say they are following ``The Guidelines.'' The Sept. CMS
guidelines were vague, ambiguous, and contained too many gaps. And
there has been no one for us to ask, unless a formal complaint is made.
Family members have feared further reprisals for complaining to their
State Nursing Division more than anything. Many are even reluctant to
call the State Ombudsman office for compassionate visitation help, out
of fear of what the facility will do going forward in disguised
retaliation.
Now CMS has new ``guidance,'' issued in March, and residents and
families have been deluded to think this will answer our prayers and
our grass roots advocacy goals. Families in many locations are still
begging for Compassionate visits. But what does a Compassionate Visit
mean? In recent interviews Evan Shulman, the Director of the CMS
Division of Nursing Home Quality and Safety, has said that they cannot
possibly define all examples of a Compassionate visit. So after a year
of lock-up, some facilities around the country are still denying these,
because ``mom has not declined enough.'' ``Dad's problems are not acute
enough.'' ``Your sister is not depressed enough.'' What? A year without
a family visit is not in and of itself reason enough to allow a
compassionate visit? Or families plead for an end of life visit, which
is sometimes denied until the very end. ``Grandma is not close enough
to death to allow you in.'' Have you seen any broad news coverage about
people who try to visit a dying loved one in a nursing home and the
police are called to escort them out, as their loved one is actively
dying? Probably not. It has been hard to get media attention to this
tragedy. But it is happening. And we see it up close and personal on
our Facebook page.
Mr. Shulman also says these compassionate visits should not ``be
routine.'' What does ``Not Routine'' mean? Some families are allowed a
15 minute visit once per week. Weekdays only. No children. Sometimes
only one visitor, maximum is two. CMS says that they ``understand.'' I
do not believe they do. They say these guidelines are what facilities
``should follow'' since they are not federal ``regulations.'' In PA,
where my parents live, the Governor and Acting Health Secretary say
facilities ``should'' follow these new guidelines, and that they
``encourage'' it. So, please help me to understand. If states say that
facilities ``should'' follow the guidelines that CMS says that they
``should'' follow, then how is any of this enforceable? Some state
Nursing Division agencies have been very helpful when people do take
the leap to make a complaint. Others side with any arbitrary
restrictions that the facility imposes. Some State Long Term Care
Ombudsman offices have been very helpful when people do take the leap
to make a request for advocacy. Others say there is nothing they can
do, placing them precisely in concert with any arbitrary restrictions
that the facility imposes. And from the family vantage point, CMS and
State regulators are doing nothing to ensure this is being understood
and universally implemented in facilities across our nation. That has
left us fighting individual battles all over the country, because they
tell us they will ``investigate'' our ``complaints'' but they have not
been proactive to clarify guidance or issue clear expectations that it
is being adhered to.
Mr. Shulman says these compassionate visits should be ``person-
centered.'' Facilities do not understand what this means on a normal
day. So, what does person-
centered even mean when every right is being taken from individuals
residing in long-term care facilities? And what gives the facility
administrator the right to measure and to determine the value and worth
and necessity of a resident being ``allowed'' to see a family member?
This is an injustice to loved ones who are seniors, adults and children
who are living in long term care. Their rights have been stripped, not
for 2 weeks which we could have probably lived with, but for a year.
How have we allowed this to happen? Where is the outrage? This is a
humanitarian crisis going on for thousands across our own country.
Right here, in the USA. People have stated this week that the disparity
of the NCAA men's and women's locker rooms and food is ``disgusting.''
The NCAA has ``apologized'' to the women. Where is the outcry over long
term care residents locked up for over a year? Who has apologized to
them? Who has given them an ounce of attention for months? Who has
cared about them? Why are people in isolation no less a disgraceful
situation than the fact that locker rooms have different equipment?
Where are our priorities?
This can never happen again, and we apparently need Regulations to make
sure that it does not happen again. I beg you to respond to this crisis
by having a Committee that will legislate humanity and compassion for
all of these residents, current and future. Because it is clear that
compassion and humanity are optional in our current world. On any given
day, I could be the next person locked up in long term care without
access to my family. Any one of you could be as well. Or your spouse or
parent or your child.
Believe me, I do not for one minute dismiss the severity of this
pandemic, nor do I have any disregard for the tremendous loss of life
it has caused. But with no one seeming to be paying any attention for
the last year, there has been an equally devastating loss of life, or
devastating loss of physical and cognitive capacity to those have
suffered alone on the inside. They have lost their will, and their
spirit, and their mental health, and their emotional health as well.
And yet facilities would deny that those individuals ``qualify'' for a
compassionate visit from a loved one? And CMS would condone the
inconsistencies in the implementation of their so-called guidelines
through their own very stance of inaction to ensure this is properly
interpreted and happening? CMS ``shoulds'' are inadequate. Our State-
based ``shoulds'' are meaningless. We need federal laws that will
mandate that Essential Caregivers are allowed for long term care
residents, even in a pandemic, and even when other regular visitation
might have to be limited for safety reasons. And I would propose that
we need another federal mandate that says that the Resident Rights, as
guaranteed and protected by the federal Nursing Home Reform Act
established in 1987, can never again be violated to the extent that we
have just witnessed. Even in a pandemic, residents should be entitled
to the ``quality of care that will result in their achieving or
maintaining their `highest practicable' physical, mental and
psychosocial well-being.'' Any thing less is unjust, immoral, and
inhumane. Just as this very tragedy has been for a full year.
Respectfully submitted
Carolyn Piper
Daughter of parents residing in Long Term Care
Member of National and PA chapters of Caregivers for Compromise--
Because Isolation Kills Too
______
Premier Inc.
444 N. Capitol Street NW #625
Washington, DC 20001
The Premier healthcare alliance appreciates the opportunity to submit a
statement for the record on the Senate Finance Committee hearing titled
``A National Tragedy: COVID-19 in the Nation's Nursing Homes.'' We
applaud the leadership of Chairman Wyden, Ranking Member Crapo and
members of the Committee for examining the factors that contributed to
the nursing home response during the pandemic and assessing necessary
improvements going forward.
Premier Inc. is a leading healthcare improvement company, uniting an
alliance of more than 4,100 U.S. hospitals and health systems and
approximately 200,000 non-acute providers, including 28,000 nursing
homes around the country, to transform healthcare. With integrated data
and analytics, collaboratives, supply chain solutions, and consulting
and other services, Premier enables better care and outcomes at a lower
cost.
It is indisputable that COVID-19 has had devastating consequences for
the nation's nursing homes. Deaths among senior-care center staff and
residents appear to represent at least 25 percent of the overall count
of more than 500,000 U.S. fatalities related to COVID-19, as compiled
by the Centers for Medicare & Medicaid Services (CMS).\1\ Since the
COVID-19 outbreak, a key focus area of Premier has been ensuring
nursing homes, which were wholly unprepared to deal with the magnitude
of the pandemic, have personal protective equipment (PPE), supplies and
equipment at their sites so they can continue to deliver high-quality
care to residents.
---------------------------------------------------------------------------
\1\ https://data.cms.gov/stories/s/COVID-19-Nursing-Home-Data/bkwz-
xpvg/.
Through two comprehensive surveys and dozens of individual
conversations to understand the needs of senior living providers during
the pandemic, Premier developed solutions and recommendations that we
shared with the Administration. In addition to supply chain issues,
which require critical thought moving forward, we believe additional
funding is necessary to implement technological supports in nursing
homes. Specifically, infrastructure is needed to help infection
preventionists and clinical pharmacists at facilities detect, manage,
control and report infection-related conditions related to COVID-19 and
beyond. We urge Congress to address known supply chain and surveillance
vulnerabilities for this unique population in the next COVID-19
package.
CONGRESSIONAL ACTION IS NEEDED TO ADDRESS
SUPPLY CHAIN VULNERABILITIES
As a supply chain leader, Premier has been at the forefront of COVID-19
response efforts and has been working around the clock to ensure a
consistent supply of medical supplies for nursing homes, including PPE.
Premier has been actively engaged with the Administration and federal
agencies to track developments and offer guidance, providing real-time
data on ordering patterns, current consumption rates and future demand
forecasts in order to inform our government's understanding of the
current state and potential future vulnerabilities.
Premier conducted several surveys \2\ to better understand the needs of
nearly 2,500 skilled nursing and assisted living facilities during the
pandemic response and found that:
---------------------------------------------------------------------------
\2\ https://www.premierinc.com/newsroom/premier-in-the-news/senior-
living-facilities-lack-supply-of-protective-gear-survey-finds and
https://www.premierinc.com/newsroom/press-releases/as-covid-19-pushes-
hospital-patients-to-post-acute-care-settings-supply-and-resource-
needs-grow-per-premier-inc-survey.
About 43 percent of senior living facilities did not have a
consistent ordering history for PPE at the outset of the pandemic,
effectively leaving them without a legitimate channel for purchasing
supplies that may be necessary to protect workers and elderly
residents. Of senior living providers that did have a consistent
purchasing history of PPE products, 87 percent were not receiving the
full quantity of products ordered at the outset of the COVID-19
pandemic.
By early April, 24 percent of senior living facilities did not
have N95 masks on hand, and the majority had fewer than 2 weeks' supply
of surgical masks, isolation gowns and face shields.
Additional products in high demand for senior living facilities
and short supply from manufacturers and distributors included
thermometers, exam gloves, shoe covers, bouffant caps, alcohol pads,
disinfecting products, hand sanitizer, and disposable paper items. This
demonstrated the unique needs of nursing homes from other healthcare
settings.
These supply chain challenges have left nursing homes
vulnerable, as 70 percent reported they are not fully prepared to treat
an increasing number of COVID-19 cases as the virus surges.
Given these findings and barriers for nursing homes to obtain PPE
through traditional distribution channels, Premier created an e-
commerce platform, Stockd, to ensure nursing homes were able to access
critical medical supplies during the pandemic in a timely manner. Built
by providers for providers, Stockd helps solve the issue of gray market
sellers and illicit marketeers that were rampant during the pandemic
through:
Robust security settings to prevent the selling of ``gray
market'' goods, or those that are sold outside of the brand owner's
approved distribution channels.
Stringent vetting policies that safeguard buyers and ensure that
they're purchasing from verified manufacturers and distributors, not
third-party sellers who may price gouge or make suspect product claims
based on market demand.
Stockd will continue to be a critical resource for nursing homes moving
forward as they adjust to the new normal and continue to obtain PPE to
protect both healthcare workers and nursing home residents.
To strengthen the supply chain to address future global pandemics,
Premier has robust recommendations on how the existing private sector
supply chain can be further enabled and augmented. Premier's guiding
principles include:
Augment the existing private sector supply chain to better
respond to global pandemics through diversification and transparency.
The private sector supply chain is highly functioning and should be
further enabled, not disrupted.
Develop a cohesive and holistic national strategy for addressing
global pandemics and stabilizing the US supply chain to respond to
surge demand for critical medical supplies and drugs.
Identify critical medical supplies and drugs needed to treat a
global pandemic and associated comorbidities. This identification
should occur via a public-
private advisory council that includes representatives from
manufacturers, group purchasing organizations (GPOs), distributors,
physicians, pharmacists, laboratorians, nursing homes, and others. This
list must be dynamic and regularly updated as technology advances, best
practices are identified, and the practice of medicine evolves.
Create upstream visibility into the supply chain to understand
sources of raw materials and manufacturing facilities. This information
is critical to assess vulnerabilities and prioritize what critical
medical supplies and drugs should be focused on initially to assure
adequate diversification of the supply chain.
Design stockpiles to create coordination rather than competition
between state, local and national stockpiles.
Invest in a robust, real time HIT infrastructure that will
provide an on-call, nimble data collection infrastructure that the
nation can call upon in any future major crises. Rather than standing
up an inadequate and duplicative system as we experienced during the
pandemic, the nation needs a system that can track critical product
availability--from the raw materials, to manufacturer, to distribution,
to hospital inventory. This system would exist behind the scenes and be
ready to be ``turned on'' in a moment's notice. This information would
inform dynamic and appropriate product allocation and distribution
strategies, minimize hoarding, and enable powerful and accurate
prediction, enabling the nation to manage supplies during the crisis.
Leverage supply and demand data from GPOs, who serve as neutral,
vendor-agnostic, and value-orientated entities to drive transparency in
the supply chain and forecast demand needs.
Advance payment and delivery system reforms that hold providers,
including nursing home providers, accountable for the health of a
population, budgets and transparent outcomes. This will incent
improving the health of a population, which will both improve patients'
comorbidities and attention to care management for sick patients.
Acting within a budget helps reduce long-term financial pressure from
rising healthcare costs.
Leverage technology to implement comprehensive infection
prevention and antimicrobial stewardship programs in nursing homes to
provide meaningful assistance with infection control.
Premier urges Congress to ensure that nursing homes are represented in
the development of a cohesive and holistic national strategy for
addressing global pandemics. Furthermore, a customized stockpile for
nursing homes should be created with appropriate supplies, drugs and
other needs.
Funding for Infection Prevention Clinical
Surveillance Will Improve Outcomes
COVID-19 has brought to the forefront the specific challenges nursing
homes face in containing the spread of infectious disease. The virus
has accelerated at nursing homes because residents are generally
vulnerable to its complications and more susceptible in the contained
space of the facilities. While data about infections in nursing homes
is limited, the CDC notes that, even prior to the pandemic, a
staggering 1 to 3 million serious infections occur every year in these
facilities and as many as 380,000 people die of the infections in
nursing homes every year.\3\
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\3\ https://www.cdc.gov/longtermcare/
index.html#::text=1%20to%203%20million%20serious,
infections%20in%20LTCFs%20every%20year.
Infection prevention oversight and training at nursing homes is a
challenge in and of itself with limited staffing and several layers of
reporting requirements. This challenge is compounded by limited
electronic health record (EHR) functionality at the sites with only an
estimated 66 percent of skilled nursing facilities currently using an
EHR.\4\ Data regarding use of EHRs in other segments of nursing homes
such as long-term care facilities and independent living are considered
to be much lower. The use of paper records in these care settings
inhibit swift data collection and proactive tracking and trending to
identify potential infections before they become rampant in the
congregate setting. Surveillance, tracking, documenting and reporting
of infections is not only necessary for COVID-19 but could be used to
better position nursing homes for future outbreaks and other indicators
that would result in improved quality of care.
---------------------------------------------------------------------------
\4\ https://www.healthit.gov/sites/default/files/page/2018-11/
Electronic-Health-Record-Adoption-and-Interoperability-among-U.S.-
Skilled-Nursing-Facilities-and-Home-Health-Agencies-in-2017.pdf.
Nursing homes now have multiple, expanded layers of infection
prevention requirements and face unique challenges with oversight and
---------------------------------------------------------------------------
training without electronic surveillance capabilities
CMS now requires facilities to:
Establish and maintain an infection prevention
and control program (IPCP) that includes, at a minimum, a system for
preventing, identifying, reporting, investigating and controlling
infections and communicable diseases for all residents, staff,
volunteers, visitors, and other individuals providing services under a
contractual arrangement.
Report on at least a weekly basis confirmed and
suspected COVID-19 cases, or face penalties.
This is on top of infection reporting requirements that vary by
state and can often require using phone, fax or mail, as well as
reporting requirements within facilities' own organizations.
Infection prevention oversight and training is challenging,
which is compounded by limited technology nursing homes due to:
High resident-to-staff ratios which are
associated with infection spreads;
A lack of on-site specialty services, such as
pharmacists for antimicrobial stewardship;
Functions that are often outsourced to outside
agencies, which then hold the data;
Surveillance, tracking and reporting processes
lack automation for everyday risks such as multidrug resistant organism
(MDRO) and for outbreaks like COVID-19.
Clinical surveillance solutions should be implemented to improve
quality and decrease costs
Clinical analytics technologies are currently widely leveraged
in hospitals and acute settings, including 46 Veterans Affairs
hospitals, to detect patient care issues through surveillance,
interventions and reporting capabilities that are needed to support
antimicrobial stewardship programs. These systems utilize data from
EHRs and have significantly helped clinicians and pharmacists in acute
settings identify overuse of antibiotics and drug-bug mismatches,
reduce time-to-appropriate therapy and enhance therapy for difficult-
to-treat pathogens. Those health systems already utilizing clinical
surveillance technology were well positioned to respond to COVID-19
before the pandemic hit. This technology is ready to optimize for
nursing homes, delivering similar results to those below.
Three Veterans Health Administration medical
centers (VAMCs) saved $2.3 million in just two years by changing the
way they administer antibiotics, using a clinical surveillance system
to ensure appropriate and safe use of antibiotics for the men and women
who have served our country.
Hartford Healthcare in Hartford, CT, streamlined
its workflow for identifying high-risk patients, conducting patient
reviews, completing documentation, and reporting infection data to
CDC's National Healthcare Safety Network (NHSN) across its six
hospitals. This saved 10 hours per week per infection preventionist,
allowing them to spend more time with clinical staff educating and
observing infection prevention processes.
Ellis Medicine, in Schenectady, NY, saved more
than $122,000 in a year by implementing clinical surveillance to meet
both New York State Department of Health and Joint Commission
requirements for stewardship to easily identify bug-drug mismatches,
duplication of therapy, and opportunities for de-escalation or
discontinuation of therapy.
Incentivizing this technology would help nursing home preparedness
beyond the COVID-19 public health emergency
We urge Congress to designate funds specifically to ensure
nursing homes can implement electronic clinical surveillance technology
(ECST) that will provide meaningful assistance with infection control.
For the purposes of the public health emergency
and for 180 days after, Congress should incentivize facilities that
already have EHRs to adopt and integrate ECST.
For those facilities that do not have existing
EHRs, Congress should designate additional resources to implement that
foundational technology and to also adopt and integrate ECST.
Unfortunately, clinical analytics technologies are currently not widely
used in nursing homes. Nursing homes should have the same access to
tools that will help them combat infection spread during any future
outbreaks of COVID-19 and during their day-to-day operations, but
unfortunately funding remains a significant barrier. Nursing homes are
already challenged with meeting their more visible needs, such as
testing and securing adequate PPE levels at their sites, but a
comprehensive approach is additionally needed to ensure data collection
is efficient, non-duplicative and being analyzed in ways that are
helpful for facilities. Furthermore, it is critical that lessons
learned from meaningful use are applied forward as we develop cohesive
solutions to address the lack of EHRs and clinical surveillance
technology in nursing homes and create appropriate incentives for
adoption.
Premier urges Congress to designate funds to incentivize nursing homes
to implement EHRs and electronic clinical surveillance technology that
will provide meaningful assistance with infection control.
CONCLUSION
In closing, the Premier healthcare alliance appreciates the opportunity
to submit a statement for the record on the Senate Finance Committee
hearing to examine the COVID-19 nursing home crisis. As an established
leader in the healthcare supply chain and healthcare data analytics,
Premier is available as a resource and looks forward to working with
Congress as it considers policy options to continue to address these
very important issues. If you have any questions regarding our comments
or need more information, please contact Soumi Saha, Vice President of
Advocacy, at [email protected] or 732-266-5472.
______
Statement Submitted by Beth Rister
Hello, I am Beth Rister from Southern Illinois. I am an educator,
currently serving as Regional Superintendent of nine counties. I
consider myself a very hard worker. While serving in a full- time job,
I also look after my mother who has Parkinson's, and is starting down
the road of dementia. I will not bore you with all the details, but
just know through a very trying year, my mother had to move from an
assisted living to a nursing home. I stood at the window of the nursing
home from May to October every evening. I tried to comfort my mother by
talking to her on a cell phone through a glass. The facility would not
allow the screen to be opened, which would have allowed fresh air in,
thus helping the ventilation and the communication. I would leave after
working all day, and standing an hour or two, crying my eyes out. It
was so hard on me, as well as on her. I could see things that needed to
be done in her room. I could see personal care that needed to be done
for her well-being. One very important thing was walking. She had
broken her hip, and she needed to walk more than 10 minutes a day. As
an essential part of her care, I would have gone in daily and walked
her, to keep her strength up. She was losing the ability to walk right
in front of my eyes. She is unable to brush her teeth appropriately due
to shaking. I again, would brush her teeth daily for her. I would help
her with her supper. Many times the tray was just set down in front of
her, and the aide (sometimes a housekeeper) would turn around to walk
out of the room. I would be knocking on the window, asking them to open
her Jell-O, her crackers, cut her meat, etc. If I had not been at the
window, she would have been unable to eat some of the items on her
tray. I know at lunch and breakfast, she was not properly cared for,
because I was unable to be at the window. There are many situations,
where essential caregivers from family are needed. The long term care
facilities are short staffed, many not properly trained. Many
residents, like my mother need so much care, and during COVID was
unable to get this care. The facility does not always have the capacity
to care for the residents like they deserve to be taken care of. These
are former hardworking members of our nation, law abiding citizens,
taxpayers, being held hostage in their last months of their life. It is
a crying shame for anyone to be treated like this, and kept from family
members who are willing to help them.
I ended up taking my mother out of the facility on October 11th. I
was not about to stand outside all winter to see about my mother. She
and my father lived very conservatively, and was able to build a small
nest egg. They never made big money, but just new how to manage. The
nursing home cost was $5,000 a month, I am now paying over $11,000 a
month for 24 hour care at home. We will be running out of money very
soon. I want to see a solution to this problem, before my mother has to
return to such a facility. I want to be able to go to her room, help
her with essential care. I shouldn't have to watch a video, take a
quiz, etc. to do so. Some of the facilities are trying to make it so
hard, people will give up. This is America, we deserve better treatment
than this! My mother was a former nursing home administrator. She ran a
fine long term care facility. The residents were like family to all the
staff. Boy, how times have changed!
I am asking you, no begging you to pass a bill, like SB 2160 to
allow one or two essential family members to enter a facility, go to
their loved one's room, to take care of the essential needs of their
loved one. There are many physical needs, as well as the social
emotional needs. They need to be shown love, not isolation.
Thank you for your time and consideration. I could care less if I
inherit a dime. I will spend ever last penny my parents saved over
their lifetime to care for my mother. My father passed in 2019, before
the pandemic. He was fortunate enough to stay home, with just 6 months
of caregivers. The money is running out very quickly. Please help.
______
Statement Submitted by Nora Toscano
I am 60 years old, and live in Tucson, AZ. I graduated from the
University of Connecticut in 1983 with a dual degree in Electrical
Engineering and Computer Science. I have been married for 36 years. My
husband is also a University of Connecticut graduate with an Electrical
Engineering degree. We have no children. I retired from Raytheon
Missile Systems as a Senior Manager Systems Engineer. Prior to COVID, I
volunteered 1 day a week at a local hospital. Recently I started
volunteering at a local AZ COVID vaccine site.
My Mom, Aneita Babicz, passed away at the age of 82 from COVID on July
7, 2020 after living in a Memory Care facility since Jan 2020.
My Mom's Story:
My Mom was diagnosed with Dementia and Early Onset Alzheimer's in late
Nov 2019 from the University of Arizona Alzheimer's Institute. I
learned dementia patients need structure, activities, and
socialization; two things my husband and I struggled to provide her
during several months that she lived with us. She became a resident of
Catalina Springs Memory Care in Oro Valley, AZ in Jan 2020. With the
environment at the Memory Care Facility, she really improved and loved
being with ``new best friends.'' She enjoyed many daily activities and
structure. I would visit her at least 3 times a week just to make sure
she was doing well and was happy. It was a great place for her.
On March 13th the Memory Care facility started implementing
restrictions due to COVID, which included no longer allowing visitors.
The staff started wearing face masks at this point.
Beginning in May residents were also given masks and were asked to wear
them when they were in the common area. Residents were also told to sit
apart from each other, and they were no longer allowed to hug each
other anymore. My Mom struggled because she needed a hug every day. But
at the same time my Mom really tried to do as she was told.
Around the end of May new mandates were imposed that all residents must
eat all meals in their own rooms by themselves (Mom had a single room).
Dementia residents need to be around each other and because of this
mandate my Mom started withdrawing and no longer ate her meals like
before. I would stop by during lunch to watch her through her closed
window, and she would just push food around on her plate. It was hard
to get her to eat. She really needed her friends to eat with her.
Initially I would call her on her own phone and talk to her during
lunch to convince her to eat. She was able to see me standing at her
window. However, being in isolation and her seeing me at her window
would only upset her more, so eventually I had to stop calling her. I
would still visit at her window but I would not let he know I was
watching her during lunch. It was so sad to watch.
The situation got worse for my Mom when a revised mandate from the AZ
Governor was issued for all Nursing Homes and Long-Term Facilities to
mandate all residents to stay in their rooms, alone, all day long. This
meant my Mom had to sit in her one chair, without a TV, or radio, and
her eyesight was bad so she couldn't read. She had no contact with
other residents all day long. This isolation does not work for dementia
patients, and it would not even work for individuals without dementia;
it is essentially solitary confinement. At times my Mom would call me
from her personal phone to complain about being mistreated. Other times
she yelled at me, her anxiety was getting worse. She did not want to be
in ``jail.'' She was done with the facility and wanted to go home. It
was really hard on me too since there was not much I could do to help.
We considered moving her to another facility but the state was not
releasing COVID test results data for Long Term Facilities so we were
unsure if we would be placing her at a greater risk elsewhere.
Being alone also caused my Mom's dementia to quickly worsen. Her
anxiety issues and her perception of reality was declining. She feared
that a big bad man was coming into her room at night to get her. I
later found out the staff would periodically peak in on residents at
night, but in the dark and with the staff wearing masks, it scared my
Mom. Therefore, my Mom was not getting much sleep at night either.
I could not reach any staff in the Memory Care Facility to help with
this matter. I kept hearing they were short staffed. It was impossible
for me to reach anyone to ask for help for my Mom or find out what was
really going on. There was no feedback for me, nor was there anyone for
me to talk to about how she was doing and how we could help her. It was
just that she was in a facility with a big wall around it and I could
not get any information personally or by phone. Communication was nil.
The facility was also not telling me much about whether a resident had
COVID or not. I heard from a friend who was an employee that a new
resident was moved into the facility with COVID, but they were
isolating that person in their room. However, the same staff that took
care of the COVID patient cared for everyone else in the facility. It
seems to me that things could have been handled better. I did not
expect the facility to admit COVID positive patients and risk my Mom's
health.
At the time COVID testing and PPE were hard to come by in AZ.
The facility did test residents for COVID, but between the months of
March and July my Mom was only tested twice for COVID, the second time
being the week before she was sent to the hospital where she was
diagnosed as COVID positive. I never did hear the results of the second
test performed by the Memory Care Facility.
On Monday June 29, 2020, my Mom, a Type II Diabetic, was found slumped
over in her room on her chair unresponsive. They called for an
ambulance which identified her with low blood sugar (12) and took her
to the local hospital. There she was diagnosed as COVID positive and
they put her in the COVID ICU ward. She was still asymptotic and doing
well for a couple days, but by Wed July 1st she took a turn for the
worse. The doctor put her on Remdesivir and Dexamethasone but she
showed no signs of improving. Since she also had heart valve issues she
did not want to be put on a ventilator. I was able to meet her doctor
in person at the Hospital on Thursday July 2nd outside the ICU ward to
get a briefing on expectations, etc., but to my surprise I was not able
to go inside the ICU ward due to lack of proper PPE. Therefore, I could
not say good-by to my Mom.
The hospital told me I would get daily updates by phone, but that did
not always happen, they were so swamped taking care of patients it was
hard for them to find the time to talk to family members on the phone.
By Sat July 4th I heard from the doctor that my Mom was not getting any
better and there was nothing more they could do for her. I was told I
needed to think about Hospice care. On Monday July 6th they transferred
her to a nearby Hospice called Casa de la Luz. I had selected them
because the assured me that they had PPE I could use to visit her once
a day.
Once at the Hospice I found out I could not go inside because they did
not have proper PPE to give me, despite what they told me in advance. I
was able to see her outside her first story open window, but at this
point she just lay in bed with her eyes closed. It was Tucson in July
and temperatures reached over 105. I saw several other families
gathered outside the windows of their dying COVID loved ones. It was
all very sad. However, I don't think my Mom knew I was there. I was
able to play her a CD of her Dad singing Irish music through her window
which I think she could hear. She passed later that night.
The last time I saw my Mom in person was March 10th. She passed, alone,
in a strange room on July 7, 2020.
Issues:
While at the Memory Care Facility there were several issues that I
believe were Systemic Failures:
Lack of availability of COVID testing and how it took way too
long for the PCR tests to be reported back to the individuals tested
(7-10 days).
Lack of sufficient available PPE for me to visit my dying Mother
in the hospital and in Hospice prior to her passing.
Inadequate staffing at the Memory Care Facility to identify that
my Mom was sick with COVID prior to sending her to the hospital, or to
identify someone else in the Long Term Facility was asymptotic with
COVID before this person was able to pass COVID on to other residents,
including my Mom.
Conclusion:
I believe there was a Systemic Failure caused by a lack of leadership
from the Federal government which flowed down to the state governments,
and in the end hurt most Long-Term Memory Care and Dementia Facilities
and their residents. If only there was cooperation and synergy among
the states and the Federal government, many lives could have been
saved.
Dementia patients cannot be treated like those in Nursing Homes and
other non-dementia patients.
PPE availability was not well regulated nor distributed, therefore
every Long-Term Facility, Hospital, and Hospice seem to be on their own
to find available PPE and were competing with each other for whatever
limited PPE was available.
COVID testing was also scarce and the few local places that were
performing PCR tests at the time were so overloaded with requests that
the test results would take 7 to 10 days, or longer. Waiting for
results for that long seem unproductive, since a lot could happen in 10
days with this rapid spread of this virus, plus the individual being
tested could get worse within these critical 10 days. In addition,
asymptomatic individuals ended up spreading the virus to those more
susceptible to COVID.
Inadequate staffing for Long Term Facilities resulted in patients who
were sick with COVID symptoms being overlooked until they got to the
point where they had to be hospitalized. In addition, results from
COVID testing on asymptomatic individuals came too late to quarantine
those asymptomatic from the rest of the residents in the facility
before they spread it to others.
Recommendation:
If the message from the Federal Government would have been consistent
and more proactive, I believe many more innocent people may have
survived 2020. Better management of PPE and COVID testing expectations,
along with separate guidance for Dementia patients vs. Nursing Homes
from the Federal Government would also have saved lives. It is a shame
that mandates like wearing masks became so political, and still is.
Individuals no longer act for the best of the national, but for
themselves.
The year 2020 was a difficult time for many Americans. Any help you can
bring to protect the welfare of our elderly, would be greatly
appreciated.
______
Statement Submitted by Michael R. Wasserman, M.D., CMD
To paraphrase the historian Toynbee, ``a society's quality and
durability can best be measured by the respect and care given its older
adults.'' I am both appreciative and disappointed by today's testimony
by John E. Dicken, ``COVID-19 in Nursing Homes: HHS Has Taken Steps in
Response to Pandemic, but Several GAO Recommendations Have Not Been
Implemented.'' With the devastation that nursing home residents and
staff have experienced over the past year, the gravity of this issue
and the urgency needed to address underlying faults in the long term
care system should be apparent. The bottom line is that there is still
much that needs to be done to protect the most vulnerable members of
our society.
One year ago I said the coronavirus was ``the greatest threat to
nursing home residents that we have seen,''\1\ and that nursing homes
could become our ``killing fields.''\2\ My experience as a clinical and
quality expert, in addition to having been the CEO of a large nursing
home chain gave me a unique perspective into COVID-19, and how existing
structural weaknesses in the nursing home industry would have tragic
outcomes. It is unfortunate, but my predictions have come to pass, with
devastating consequences in nursing homes across the country.
---------------------------------------------------------------------------
\1\ https://www.nbcnews.com/health/health-news/coronavirus-nursing-
homes-greatest-threat-years-here-s-what-they-n1153181.
\2\ https://www.cbsnews.com/news/coronavirus-nursing-home-death/.
I am board certified and fellowship trained in geriatric medicine. In
1989, I opened Kaiser-Permanente's first outpatient geriatric consult
clinic and in 1994 founded Kaiser's second Continuing Care Department
in the country. I subsequently went on to become the president and
chief medical officer of GeriMed of America, a geriatrics medical
management company, before founding Senior Care of Colorado, which
became the largest primary care geriatrics private practice in the
country at the time. I was the Executive Director, Care Continuum,
overseeing the nursing home arm of Medicare's California QIN-QIO. I
then became the chief medical officer overseeing the largest nursing
home chain in California, becoming their CEO for fourteen months before
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resigning in November of 2018.
From the moment that I heard about the outbreak at Life Care Center of
Kirkland, my entire body of experiences informed me as to what was
coming. I have been working ever since attempting to educate policy
makers and government officials in order that they might have a better
understanding of the nursing home industry in order to better protect
residents and staff. My first articles published in March were focused
on the need for effective infection prevention, including a focus on
the front line staff.\3\, \4\
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\3\ https://www.mcknights.com/blogs/a-mantra-in-wake-of-
coronavirus-stay-home-and-save-a-life/.
\4\ https://www.linkedin.com/in/mike-wasserman-8535676/detail/
recent-activity/posts/.
On February 29th, with the outbreak of COVID-19 in a Washington state
nursing home, the experts in geriatrics and long term care medicine
knew what was coming. Many of us did everything in our power to sound
the alarm. Unfortunately, our voices were not heard in a timely
fashion. We must all live with the dire consequences. We must also
recognize and thank the incredible people who serve on the front lines
in nursing homes. They are incredibly caring and compassionate human
beings, many of whom don't even make a living wage. Media accounts of
nursing home care all too often ignore their efforts. Too many have now
given their lives unnecessarily due to the lack of immediate action to
this pandemic on the part of the federal government, the state, the
---------------------------------------------------------------------------
counties and the nursing home industry.
COVID-19 ultimately made its way into most nursing homes. There are
those who use this fact to create a false narrative that there was
little that could have been done to have significantly reduced the
devastating impact of this virus on nursing home residents. Nothing
could be further from the truth. There was a lot that could have been
done, and we must honor those who have died by taking action to
reimagine the nursing home industry. My comments will focus first on
the pandemic response, as there are specific operational elements that
should be reviewed and can not be ignored. However, these elements are
only the beginning, and we have been fortunate to already have the
beginning of a roadmap for the future put forth by the Coronavirus
Commission on Safety and Quality in Nursing Homes, which I suggest
should immediately be reconstituted in the form of a Federal Advisory
Committee. Many of their recommendations should immediately be acted
on. The dissenting opinion must not be ignored and needs additional
work in order to achieve consensus. Those who have given their lives
deserve this level of attention.
In April of 2020, CALTCM published our ``Long Term Care Quadruple Aim
for COVID-19 Response,''\5\ the pillars of which have withstood the
test of time and continue to reflect the key elements necessary to
combat this deadly virus. CALTCM's Quadruple Aim was developed and
shared with the California Department of Public Health (CDPH) in March,
and with CMS in April, and was posted on the CALTCM website on April
17th. It starts with the need for every nursing home to have an
abundance of Personal Protective Equipment (PPE). Pandemic supply chain
dynamics made procuring PPE challenging. The state, counties and
facilities did not have the wherewithal to transcend this challenge in
order to obtain PPE for every nursing home. As we know, the federal
government, through the DPA process, had the ability to surmount this
challenge and should have immediately done so. Additionally, and
pertinent to reimagining nursing homes, real estate owners and REIT's
behind the nursing home industry had the ability to leverage their
assets to acquire PPE, and generally chose not to intervene. As a
clinician, I don't care who takes responsibility for the acquisition of
PPE, it just has to happen. Without PPE, COVID-19 can't be stopped.
While everyone was complaining about the lack of PPE and the inability
to acquire it, nursing home residents were infected with the virus and
died. Even today, according to Mr. Dicken's testimony, ten percent of
nursing homes still struggle to have adequate PPE. This is
unacceptable. The single most important intervention (prior to the
availability of a vaccine) in nursing homes, assisted living facilities
and group homes is an abundance of PPE. In the future, the government
and the industry must transcend all obstacles and assure that a lack of
PPE will never again get in the way of protecting vulnerable older
adults.
---------------------------------------------------------------------------
\5\ https://www.caltcm.org/assets/
CALTCM%20COVID19%20QUADRUPLE%20AIM%20FI
NAL.pdf.
The second element of the Quadruple Aim is readily available testing.
Nursing home staff were the main vector for transmission of the virus.
CALTCM convened a group of experts who developed recommendations
related to testing.\6\ Testing of all staff was critical to protecting
both the residents and the staff themselves. Telling nursing homes to
come up with their own plans for testing was never the answer. The
federal government should have used its clout and resources to assure
that testing was performed and that labs prioritized the processing of
the tests. The nursing home industry should similarly have supported
testing by actions rather than words. In the coming months and years,
we will hear many stories of where this did not happen due to
fundamental weaknesses in both our government and the industry. What is
truly unfortunate is that even today our country's testing capabilities
are not state of the art.
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\6\ Wasserman M, Ouslander JG, Lam A, et al. Editorial: Diagnostic
Testing for SARS-Coronavirus-2 in the Nursing Facility: Recommendations
of a Delphi Panel of Long-Term Care Clinicians. J Nutr Health Aging.
2020;24(6):538-443. doi:10.1007/s12603-020-1401-9.
Stellar infection prevention is the third element of the Quadruple Aim.
The Centers for Disease Control and Prevention, and countless
Departments of Public Health across the country worked tirelessly to
provide nursing facilities with infection control training.
Unfortunately, that approach was always going to be insufficient if the
nursing home industry wasn't fully on board with embracing the role of
infection preventionist's to their fullest extent. The worst kept
secret in the nursing home industry is the fact that the infection
preventionist (IP) is not allotted the time necessary to do an
effective job. Furthermore, the key reason for requiring a full-time IP
is the need to literally ``hot-wire'' the nursing home chain of
command. Most nursing home administrators are focused on their census,
and also lack expertise in clinical areas. One of the immediate
solutions to the COVID-19 pandemic that we developed was the concept of
a virtual centralized support and guidance center that could provide
expertise to individual nursing homes on a daily basis. Such a support
and guidance center could have been used to support COVID-19 positive
nursing homes. CALTCM published a white paper on this in April,\7\ and
a paper on the concept in July.\8\ We also shared this concept with
CDPH and CMS in March and April, respectively. The need to specifically
engage the IP was one element of our recommended approach. In fact, on
March 13th, CALTCM proposed that every nursing home in California be
mandated to require their designated infection preventionist (IP) be
full-time. It took nearly 3 months for the CDPH to make this
recommendation part of every nursing home's mitigation plan. In the
fall, Governor Newsom signed AB 2644, making it a requirement that
every nursing home in California have a full-time infection
preventionist. The recommendation requiring the need for full-time
infection preventionists was also made to CMS in April, countering
previously watered down guidance in the nursing home regulations. We
must do everything possible to support the role of the facility IP.
Doing this early in the pandemic would have improved the success of the
federal and state governmental efforts. Effectively impacting the
operations of nursing homes requires a paradigm shift with a focus on
the improved delivery of clinical care. The requirement of a full-time
IP is a necessary, but not sufficient, step in the right direction.
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\7\ https://www.caltcm.org/assets/
WHITE%20PAPER%20A%20Plan%20to%20Protect%20Our%
20Nursing%20Home%20Residents%20.pdf.
\8\ Wasserman M, Wolk AJ, Lam A. Jour Nursing Home Res, 2020;6:24-
29. An Aspirational Approach to Nursing Home Operations During the
COVID-19 Pandemic. http://dx.doi.org/10.14283/jnhrs.2020.6, https://
www.jnursinghomeresearch.com/2263-an-aspirational-approach-to-nursing-
home-operations-during-the-covid-19-pandemic.html.
The fourth and final element of the Quadruple Aim is that nursing homes
must operate in their emergency preparedness mode. This is essentially
a proxy for excellent leadership and management. If COVID-19 has shone
a light on one thing, it's the inherent weaknesses in the management
structure of nursing homes. Nursing homes are complex small businesses,
delivering care to frail older adults with multiple chronic illnesses.
They are literally mini-hospitals, but with far fewer resources.
Nursing home administrators are not prepared to run a hospital, and
should not be expected to have the skills necessary to manage a
facility during a pandemic. More importantly, running a ``mini-
hospital'' should require the full engagement of physicians competent
in the care of complex, frail, older adults. A significant number of
the nursing home deaths brought on by this virus were preventable. If
there is an overarching message from the COVID-19 pandemic, it's the
need to actively engage experts in geriatrics and long term care
medicine in the policy and decision making processes that impact the
lives of older adults. To the clinical experts this pandemic has never
been about control, money or power. It's been about saving lives.
Despite the Herculean efforts of experts in geriatrics and long term
care medicine, we've literally had to beg for table scraps to weigh in
on policies with county, state and federal government officials, much
less the nursing home industry itself. Some have had a greater impact
than others, but this never should have been this way. We must learn
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from this experience.
The evolution of nursing homes from post-war rest homes to today's
``mini-hospitals'' began with implementation of the hospital DRG system
in 1983. There was a brief period in which hospitals purchased nursing
homes. They quickly realized that they could discharge patients to
nursing homes without taking responsibility or accountability for the
outcomes. Meanwhile, nursing home investors learned how to make
substantial profits from Medicare and Medicaid without regard to
quality of care. COVID-19 has unmasked a deeply flawed industry. The
existing oversight of the nursing home industry has not worked to
protect residents or staff during this pandemic. The survey process as
implemented today does not work. It is time to lead the way in
developing an effective oversight and quality improvement process.
Surveys often worsen staff morale and have not been shown to have
significant demonstrable benefit. The focus of surveys must be on
improving the delivery of care and protecting the quality of life of
the residents. We support active oversight, and believe that it is
critical for CMS to engage experts in geriatrics and long term care, as
well as resident advocates, in developing a new and more effective
process for carrying out federally mandated surveys. An AMDA Task Force
published a paper regarding this in the fall, and those of us who have
served on the front line of nursing home care over the past few decades
are ready and willing to engage in improving this important process.\9\
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\9\ Nazir A, Steinberg K, Wasserman M, et al., JAMDA, Time for an
Upgrade in the Nursing Home Survey Process: A Position Statement From
the Society of Post-Acute and Long-Term Care Medicine. 2020, ISSN 1525-
8610, https://doi.org/10.1016/j.jamda.2020.09.022.
Where does this leave us? This past summer the Coronavirus Commission
on Safety and Quality in Nursing Homes met and produced a list of
recommendations that settled on ten themes. Unfortunately, instead of
acting on these recommendations, CMS leadership at the time chose to
act as if they had already been following the recommendations. Nothing
could have been further from the truth, which was alluded to in Mr.
Dicken's testimony. I will proceed to review these recommendations as
they form an excellent framework for how we might reimagine the nursing
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home industry as we go forward.
Testing and screening was ``Theme 1'' of the report. While the worst of
the pandemic is over, and we now have vaccines, testing is still a
critical issue, especially in regards to variants. A DPA level approach
to testing should have been taken, and we still need that type of
approach. With the ongoing growth of variants, it is essential that we
aggressively sequence variants that are being found in nursing homes.
From the beginning of this pandemic, it was essential to provide rapid
turnaround of Pcr testing. Ideally, we should have point of care Pcr
testing by now. It is unconscionable that all Pcr testing provided to
nursing homes does not have less than 24 hour turnaround. In lieu of
Pcr testing, antigen testing has provided an alternative approach to
point of care testing. There are opportunities to provide home antigen
tests to nursing home staff. The testing doesn't have to start and end
with COVID-19. Similar tests are available for influenza and other
viruses. We need to take advantage of what we've learned during this
pandemic to reduce the impact of other deadly viruses that have plagued
nursing homes in the past. There are continued opportunities to reduce
both false negatives and positives.
Equipment and personal protective equipment were in ``Theme 2'' of the
report. Every nursing home in the country MUST have an abundant supply
of PPE. This is critical not only for COVID-19, but for other
communicable diseases. Furthermore, N95s are essential, and no nursing
home should ever be at risk of running out. There is a critical need to
address supply chain issues so that they never occur again. There is
also the need to assure that any financial support is effectively put
towards PPE and testing equipment.
Cohorting was covered in ``Theme 3'' of the report. We have the
opportunity to learn from our COVID-19 pandemic experience to evaluate
the best ways to balance resident and staff safety with infection
prevention and control. During the early months of the pandemic, the
waiving of resident transfer and discharge requirements had many
unintended consequences. For this reason, it is critical that evidence
and science drive cohorting guidance.
Visitation was addressed in ``Theme 4'' of the report. While the
decision to restrict visitation made immediate sense due to the lethal
nature of COVID-19, it also contributed to social isolation. The
consequences of social isolation have been found to have been
significant. With the advent of fully vaccinated nursing home residents
and the increasing percentage of staff vaccinations, we have turned a
corner. But there is still a lot of work to be done in order to
maximize safety when allowing visits to and from friends and family.
Visitation is a vital resident right and nowhere is the collaboration
between the CDC and CMS more critical. The term
person-centered care is bandied about, but in order to make the care of
nursing home residents truly person-centered we must fully engage
experts in geriatrics and long term care medicine in developing the
most effective approaches. CALTCM has used a modified Delphi process to
make visitation recommendations,\10\ but in order to create expert
driven guidance to fully address the risks and benefits of these
approaches, CMS should convene similar groups of experts to assist in
developing future guidance.
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\10\ Bergman C, Stall NM, Haimowitz D, Aronson L, Lynn J, Steinberg
K, Wasserman M. Recommendations for Welcoming Back Nursing Home
Visitors During the COVID-19 Pandemic: Results of a Delphi Panel. J Am
Med Dir Assoc. 2020 Dec;21(12):1759-1766. doi: 10.1016/
j.jamda.2020.09.036. Epub 2020 Oct 7. PMID: 33256956; PMCID:
PMC7539058.
Communications was ``Theme 5'' of the report. Throughout the pandemic
ineffective communications have challenged the implementation of
programs and guidance to nursing homes across the country. There needs
to be increased specificity and expansion of guidance in regards to
communications. While the concept of heath literacy is normally thought
of in relation to interacting with patients, it also pertains to how we
communicate with nursing home staff and the families of residents. In
addition to effective guidance and communication with nursing homes,
how the CDC and CMS communicate with each other also matters. Improving
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communications can be facilitated by fully engaging the QIN-QIOs.
The workforce ecosystem was ``Theme 6'' of the report. There are people
in our society who are unable to be cared for at home. Older adults and
younger disabled individuals requiring a nursing home level of care
often have complex medical needs. Many have cognitive impairment or
dementia. Most persons living in nursing homes need assistance with
activities of daily living, whether it be for toileting and bathing, or
for transferring out of a bed or chair. Meeting the needs of these
residents requires an educated and well trained staff. The literature
prior to and throughout the pandemic has been clear in relation to the
need for appropriate levels of staff. A CMS study in 2001 established
the importance of having a minimum of 0.75 registered nurse (RN) hours
per resident day (hprd), 0.55 licensed nurse (LVN/LPN) hprd, and 2.8
(to 3.0) certified nursing assistant (CNA) hprd, for a total of 4.1
nursing hprd to prevent harm or jeopardy to residents.\11\ As part of
this study, a simulation model of direct care workers (CNAs)
established the minimum number of staff necessary to provide five basic
aspects of daily care in a facility with different levels of resident
acuity. A more recent study shows that for the highest acuity nursing
homes, CNA staffing should be 3.6 hprd.\12\ For the lowest resident
workloads, this converts to 1 CNA for every 7 residents on the day and
evening shifts and 1 CNA to 11 residents at night. For the heaviest
resident workloads, 3.6 CNA hprd converts to 1 CNA for 5.5 residents on
days and evenings and 1 CNA for every 11 residents on nights.
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\11\ Centers for Medicare and Medicaid Services. Report to
Congress: Appropriateness of Minimum Nurse Staffing Ratios in Nursing
Homes Phase II Final Report. Baltimore, MD: Centers for Medicare and
Medicaid Services; 2001.
\12\ Schnelle JF, Schroyer LD, Saraf AA, Simmons SF. Determining
nurse aide staffing requirements to provide care based on resident
workload: A discrete event simulation model. JAMDA. 2016; 17:970-977.
A number of organizations have endorsed the minimum of 4.1 hprd
standard, and have suggested that at least 30 percent of hours should
be provided by RNs and LVNs/LPNs and facilities should have 24-hour RN
care.\13\, \14\, \15\ Some experts have
recommended even higher staffing standards (a total of 4.55 hprd) to
improve the quality of nursing home care, with higher adjustments for
higher resident acuity.\16\ These numbers can not be a ceiling, but
must become the floor. Efforts must be taken to ensure that nursing
homes provide greater levels of staffing as appropriate based on
acuity. The other issue that begs clear direction from CMS is in
relation to having full-time Infection Preventionists. There should be
a minimum of one full-time IP for all facilities with greater than 40
beds, and the number of full-time equivalents should increase
proportionally for facilities with greater than 100 beds. There also
needs to be clear training guidelines and consideration of
certification requirements for this position.
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\13\ Institute of Medicine. Keeping patients safe: transforming the
work environment of nurses. Washington, DC: National Academy of
Medicine, 2004.
\14\ American Nurses' Association. Nursing staffing requirements to
meet the demands of today's long term care consumer recommendations
from the Coalition of Geriatric Nursing Organizations (CGNO). Position
Statement 11/12/14, www.nursingworld.org.
\15\ Coalition of Geriatric Nursing Organizations (CGNO). Nursing
staffing requirements to meet the demands of today's long-term care
consumer recommendations, 2013.
\16\ Harrington C, Kovner C, Kayser-Jones J, Berger S, Mohler M,
Burke R. et al. Experts recommend minimum nurse staffing standards for
nursing facilities in the United States. Gerontologist. 2000; 40 (1):1-
12.
Workforce systems were ``Theme 7'' of the report. There has been a lot
of discussion prior to and during the pandemic around a lack of
interest for working in nursing homes. We clearly must address wages
and benefits if we are to catalyze interest in becoming CNAs or having
nurses work in nursing homes. It is time to overhaul the entire
workforce ecosystem. The Commission recommended convening a LTC
workforce commission. I concur with this recommendation, and would
suggest that such a commission be tasked with quickly making actionable
recommendations that can be implemented in the near future. There is
also evidence that certified medical directors are associated with an
increase in nursing home quality \17\ and there are many anecdotal
reports of engaged medical directors making a difference during the
pandemic. The average 99-bed nursing home is an approximately $10
million per year complex business. Local nursing home leaders are
rarely prepared to run such a complex business. The nursing home
administrator is essentially the CEO of the business. What training is
required to be a nursing home administrator? What about the director of
nursing? They are the chief operating officer, managing and leading an
inadequately trained and often poorly paid clinical workforce to
provide care for some of the most complex persons in our history. A
hospital organizational chart includes physicians at the highest
levels. Where is such physician engagement in today's nursing homes?
Effective teamwork and leadership from Medical Directors, NH
administrators, and Directors of Nursing are critical for nursing
homes, particularly in a pandemic, and ineffective teaming signals a
critical need for leadership training.\18\, \19\ Variation
in leadership style and high levels of turnover also impede the
establishment of stable leadership in nursing homes.\20\ This then
impacts staff turnover and quality of care.\21\ Enhancing leadership
and management training for nursing home leadership teams is a key area
that hasn't been fully discussed and desperately needs attention.
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\17\ Rowland FN, Cowles M, Dickstein C, Katz PR. Impact of medical
director certification on nursing home quality of care. J Am Med Dir
Assoc. 2009 Jul;10(6):431-5.
\18\ https://onlinelibrary.wiley.com/doi/full/10.1111/jgs.16513.
\19\ Maas ML, Specht JP, Buckwalter KC, Gittler J, and Bechen K.
(2008). Nursing home staffing and training recommendations for
promoting older adults' quality of care and life: Part 2. Increasing
nurse staffing and training. Research in Gerontological Nursing, 1(2),
134-152.
\20\ Williams G, Wood EV, and Ibram F. (2015). From medical doctor
to medical director: Leadership style matters. British Journal of
Hospital Medicine, 76(7), 420-422
\21\ Donoghue C, and Castle NG. (2009). Leadership styles of
nursing home administrators and their association with staff turnover.
The Gerontologist, 49(2), 166-174.).
Historically, physicians have been engaged by nursing homes with the
express purpose of helping to fill beds, or to satisfy a specific
regulatory requirement. It is highly unusual for physicians to be
engaged in facility leadership and operations. This concept would be
anathema in the hospital setting, but has been readily accepted in the
nursing home industry. AMDA, now called the Society for Post Acute and
Long Term Care Medicine, was founded in 1977 and two years ago passed a
resolution to the effect that the role of the nursing home medical
director should have nothing to do with referrals.\22\
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\22\ https://paltc.org/amda-white-papers-and-resolution-position-
statements/policy-e19a-medical-director-compensated.
The American Board of Post-Acute and Long-Term Care Medicine provides a
certification for nursing home medical directors. There are 1240
nursing homes in California and only 125 certified medical directors.
This percentage is similar nationally. The vast majority of medical
directors in nursing homes around the country are not fully engaged
with their facility leadership team. This has a negative impact on
quality during normal times, but the impact has been amplified during
the pandemic. Whether in dealing with COVID-19, or trying to provide
quality care in the future, it is essential that the clinical experts
be actively involved in the day to day operations of nursing homes. It
is important that medical directors be allowed to perform their duties
without undue influence from nursing home ownership. There should be no
quid pro quo related to admissions, and medical directors should feel
free to provide leadership and make recommendations regarding the
delivery of care without fear of losing their position. One of my
colleagues lost their medical director position early in the pandemic
in order to be replaced by hospitalists who were perceived as providing
a source of admissions to the facility. The best way to avoid such
behavior would be to require certification for all nursing home medical
directors. In California, Assemblyman Nazarian has introduced AB 749,
requiring certified medical directors for every nursing home in the
state. Until this happens at a national level, The Society for Post
Acute and Long Term Care Medicine (AMDA) has requested that CMS create
a registry of all medical directors in the country, so that we might
directly communicate with them and offer resources and support for this
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vital role.
Technical assistance and quality improvement were ``Theme 8'' of the
report. We must increase the availability of onsite collaborative,
data-driven support. The QIN-QIOs must be effectively engaged. This
means eliminating the need for QIN-QIOs to ``recruit'' nursing homes
and to require them to participate. It is also necessary to reduce the
QIN-QIO's administrative burden. Too much time and energy is spent with
needless reports, when that time could be better spent with on-site
training.
Facilities were ``Theme 9'' of the report. It is time for facility
design enhancement. This includes addressing ventilation, space,
capital incentives. It means considering approaches such as the Green
House model.
Nursing home data was ``Theme 10'' of the report. There must be a
comprehensive retrospective look at COVID-19 data beginning in January
2020. We must capture the deaths related to COVID-19 (residents and
staff), regardless of location at the time of death. There must also be
an accounting of adverse events secondary to social isolation such as
functional decline, weight Loss, pressure ulcers, and behavioral
symptoms. Retrospective COVID-19 data must include a look at Pcr
testing data (residents and staff), to include turnaround time, as well
as an analysis of screening with and without outbreaks. Similarly,
antigen testing data (residents and staff) must be similarly analyzed.
Prospective data analysis must focus on genetic sequencing of variants
and the value of both Pcr and antigen testing (staff and residents) in
fully vaccinated nursing homes.
There is little disagreement regarding the fact that the financial
structure of nursing homes is not conducive to maximizing scarce
resources while providing quality care to residents. The separation of
real estate, operations and management is a contrivance that leads to
unmanageable pressures. The additional pressure from liability
insurance costs compounds these pressures. It is time to bring
transparent change to the ownership maze and consolidate nursing home
ownership so that the full focus can be on delivering care to the
residents. This is a complex topic that in and of itself is worthy of
an entire tome. As someone who was the CEO overseeing the largest
nursing home chain in California, it would be my privilege to testify
before this committee on this topic. In the meantime, I would make a
recommendation to help take the pressure off of nursing home operators
during this challenging time. I suggest that nursing homes be exempted
from paying rent and liability insurance premiums for the next six
months. The costs of this would obviously be borne by the real estate
owners and the insurance companies. I believe that it's time for them
to do their part while we figure out how the nursing home industry can
survive and come out stronger than it was before.
In order to imagine the future of nursing homes, picture a three-legged
stool. If the three legs aren't equal, the stool will fall over. The
legs represent Finance, Operations and Clinical Services. Rarely at the
facility level or the corporate level of a large chain, are these
treated equally. One will almost never find Clinical Services being
given the same attention as Finance and Operations. This is the
fundamental, and in the case of COVID-19, the fatal flaw in how today's
nursing homes operate. If clinical services are not treated equally,
the nursing home industry cannot, and I might say should not, survive.
Effectively providing care for a complex group of individuals requires
competencies at every level of the organizational chart. Aside from
having an appropriate level of staffing, nursing homes require properly
prepared, highly skilled leadership teams that can balance the
financial, operational and clinical aspects of this incredibly complex
business. Which brings us to a specific roadblock that has prevented us
from advancing beyond the status quo.
A recent study demonstrated higher mortality and higher taxpayer
expenditures related to private equity in the nursing home
industry.\23\ This study puts the impact of the pandemic in stark
perspective. Today's nursing home industry attracts investors primarily
because of its real estate and ``related party''
potential.\24\,\25\ As long as real estate is the primary
driver of financial success, and related parties are allowed to siphon
money away from operations, the nursing home industry as a whole will
continue to fail to provide value and quality. The COVID-19 pandemic
has demonstrated the importance of having immediate access to financial
reserves, but those potential funds have been converted into real
estate capital and private equity. That capital could have been
effectively leveraged to provide for abundant PPE and testing as well
as for additional staff. Instead, for the most part, that capital
either sat on the sidelines or was leveraged for other purposes such as
buying more real estate. If we are going to reimagine nursing homes,
the clinical operations must have access to these funds.
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\23\ Gupta A, Howell ST, Yannelis C. Does Private Equity Investment
in Healthcare Benefit Patients? Evidence from Nursing Homes. National
Bureau of Economic Research Working Paper Series, No. 28474, February
2021. 10.3386/w28474, http://www.nber.org/papers/w28474.
\24\ Harrington C, Ross L, Kang T. Hidden Owners, Hidden Profits,
and Poor Nursing Home Care: A Case Study. Int J Health Serv.
2015;45(4):779-800. doi: 10.1177/0020731415594772. Epub 2015 Jul 9.
PMID: 26159173.
\25\ https://www.washingtonpost.com/business/2020/12/31/brius-
nursing-home/.
The Medicare Payment Advisory Commission produces highly precise
reports of nursing home profitability that are based on the same
illusion about the structure of nursing home finances. As the
Government Accounting Office has demonstrated time and again, our
government's attempts to secure quality and value from its investment
have been outmaneuvered by private sector accountants and attorneys. We
must illuminate and address the structural dynamics that successfully
sustain the substandard status quo. In a recent Health Affairs
Blog,\26\ we published a set of recommendations to address
transparency. The tentacles of related parties have a negative impact
on facility finances and operations. One of the unseen consequences of
the existing related party structure is the upward pressure on costs
that not only impacts for-profit nursing homes, but non-profits as
well.
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\26\ https://www.healthaffairs.org/do/10.1377/hblog20210208.597573/
full/.
Oversight and enforcement are catch-all phrases that policymakers wield
as solutions to poor quality in nursing homes. The government deploys
its oversight strategies based upon an illusion that nursing home
operators constitute the industry, ignoring the role of the real
estate, related party owners and private equity. Applying penalties to
the operations of nursing homes has not generally been shown to be an
effective means for improving quality. The largest owners appeal and
delay payments, sometimes for years, while non-profits and ``mom and
pop'' nursing homes struggle under the weight of hefty penalties that
may be misguided and don't support quality improvement. I recently
participated in, and co-authored a paper making recommendations for
upgrading the survey process.\27\ In my opinion, the only way to
address this issue is to convene a Commission composed primarily of
clinical experts, regulatory experts and advocates.
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\27\ Nazir A, Steinberg K, Wasserman M, et al., JAMDA, Time for an
Upgrade in the Nursing Home Survey Process: A Position Statement From
the Society of Post-Acute and Long-Term Care Medicine. 2020, ISSN 1525-
8610, https://doi.org/10.1016/j.jamda.2020.09.022.
Nursing homes are also weighed down by liability insurance costs that
are compounded by this sector's perpetual quality issues. The insurance
industry has little incentive to reduce premiums. Ironically, both
plaintiffs' and defense attorneys have little incentive to see a change
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in the system. Nursing home liability must be thoughtfully reformed.
The nursing home industry and the government must also fully engage
experts in geriatrics, post-acute and long-term care medicine,
geriatric psychiatry, as well as experts in the care of the growing
younger population of nursing home residents with disabilities and
psychiatric conditions. Nursing home policy cannot be effectively
imagined or implemented without these experts' active involvement.
The more subtle threats to the nursing home industry come from
ignorance and arrogance. Ignorance related to the lack of understanding
of how a geriatrics-focused, team-based approach to care is essential.
Arrogance related to the fact that we can no longer keep running
nursing homes as we have for the past four decades. If we are to
reimagine nursing homes, we must be certain that the clinical focus is
never allowed to be subservient to the finances. The entire industry
must be reimagined. We must start by assuring appropriate staffing. The
staff must be trained and must earn a living wage with corresponding
benefits, and turnover must be reduced. Leadership teams must set their
primary focus on providing quality care. We cannot afford money being
siphoned out of facilities toward excessive real estate, related party
and insurance industry profit. The residents we care for deserve to be
prioritized. After nearly a year of hell, where all have been cut off
from their loved ones, and many have lost their lives, we owe them that
much.
I want to close by reiterating the fact that experts in geriatrics
across the country would relish the opportunity to assist in the
development of policy related to the health and well-being of frail
older adults. This is what we've spent our lives training for. Many of
us were inconsolable as the federal government, the Departments of
Public Health and many counties made decisions without the full input
of the clinical experts throughout this pandemic. It is time to learn
from these mistakes and develop a structure that allows for the
development of expert-driven policy. I plead with you to find a way to
encourage the direct involvement of the experts as we move forward. If
such a process had already been in place, a significant number of lives
would have been saved.
______
Letter Submitted by Rachel Winters
Dear esteemed representatives:
I am a registered voter in Pennsylvania (Westmoreland County) and I am
writing to share my story, like others across the Commonwealth, who
have family in assisted living/long term care facilities. The
restrictions during the COVID pandemic placed on these facilities by
the Pennsylvania Department of Health, CDC, and Centers for Medicare
and Medicaid have adversely affected the quality of life for the
constituents that rely on these facilities for their care.
My father, Herbert Henderson, is a veteran of the United States Air
Force and proudly served his country in Vietnam. In November of 2019,
my father had a series of strokes that impaired his speech and
mobility. He was in and out of hospitals and rehabilitation facilities
spending a total of 14 days at home since November 26, 2019. We placed
him at Saint Anne's Home in Greensburg, PA on March 8, 2020 for further
physical and occupational therapy. Saint Anne's was shut down on March
13, 2020 because of the COVID-19 outbreak. My family decided to let my
father complete his therapy at Saint Anne's and wait to see if we could
witness his progress to determine if my 75 year old mother could care
for him at home. That opportunity never came.
We had to send my father to the hospital twice during the COVID
pandemic, once in May for congestive heart failure and again in July
for colitis and C. Diff. Each time we had to weigh the decision to send
him out knowing that he would be in quarantine for 10-14 days upon
returning to Saint Anne's. Each time he had to quarantine after a
hospitalization was excruciating. He would become agitated, his speech
was slurred and difficult to understand, and the last hospitalization
he lost the ability to feed himself with utensils.
The first time my father was able to go outside was for a table visit
in August, 3 months after arriving to Saint Anne's. The facility is
hard pressed to retain staff given the current health crises, so there
isn't enough people to get him outside to enjoy the sunshine on his
face or hear the birds in the trees. This is something we did with him
every time we visited for the short period we were allowed in the
building. We went up every day, for two hours and made sure he got
outside in one of Saint Anne's beautiful gardens. My dad loves to be
outside.
My family and I have followed every protocol and abided by every
changing rule and regulation sent down by the state and the CDC. We
were allowed 2 compassionate care visits with my dad and 13 table
visits which were 20 minutes in length, with an 8 foot table separating
us.
Despite the frequent COVID tests of staff, not seeing family/friends,
and the severe reduction in social activities, my father contracted
COVID-19 the end of November 2020. He was isolated in his room for 3
weeks with the door shut and covered in plastic. The only view he had
was to an interior courtyard, which meant that we could not visit. The
ventilation system in his room that was to circulate air and prevent
the virus from getting into the building made it impossible for him to
hear us on the phone. Not only could we not see him, we couldn't talk
to him either. The only interaction he had was with the nurses and
aides who worked at Saint Anne's, many whom were unfamiliar to him
because his usual care staff had also contracted COVID. He spent
Thanksgiving alone in his room. When he was finally released from
isolation, he was a shell of a man. My mom and I went up for our usual
window visit and he wouldn't speak to us, just staring out into space.
The lack of stimulation via activities, communal dining, and personal
contact is taking a toll on all residents in personal care/long-term
care facilities. These individuals haven't committed any crimes and yet
they are being punished for getting old, frail and sick. These homes
are understaffed and overwhelmed trying to keep up with the regulations
and rules placed upon them. It is an extreme disservice to the people
in these facilities, their families, and the staff that we are over a
year into this pandemic and there is no end in sight. The COVID
pandemic is killing off the elderly not by contracting the virus, but
by disengaging them for everyday life. They are sitting in their rooms
in front of a TV waiting to die.
In December, we were notified that my father isn't doing well. He
hadn't eaten anything for 3 weeks; he ripped out the IV meant to
provide him hydration; he was refusing blood work and his medications;
he was telling everyone at Saint Anne's that he wants to die. We were
advised to sign him up for hospice because he is in the twilight of his
life. We were allowed two compassionate care visits and one tent visit
when his conditioned worsened. Then the infection rate in Westmoreland
County increased and based on the regulations we are not allowed in
Saint Anne's to see my dad. We got to watch him slowly deteriorate
through a pane of glass.
My mom and I have been up at my dad's window at 3-5 days a week since
the lockdown for at least an hour. We were sitting out there in the
rain, snow, and freezing temperatures. We want him to know that he is
not forgotten. He doesn't understand why we can't come in there and sit
next to him on his bed or hold his hand.
Countless birthdays, holidays, and anniversaries were spent either
looking at my father through a closed window or separated by an 8 foot
long table with a Plexiglas barrier. No touch. No physical contact. An
entire year has gone by without being able to take my dad outside to
one of the courtyards to hear the birds sing or walk him up and down
the halls of the facility. My parents have been married 57 years. This
is the longest that they have not been physically together since my dad
was in the Air Force and deployed.
When he was admitted to Saint Anne's he was walking with a walker, able
to feed himself, and called us on his cellphone. Now a year later, he
requires two people and a lift to get him in and out of bed. He no
longer remembers how to answer his phone, let alone call us to talk.
His fine motor abilities have declined. I take him finger foods and
watching him trying to pick up his food is painful. He has lost 40
pounds this year. His speech also suffered. He is hard to understand,
even on his best days.
Thankfully he has improved since December. Saint Anne's started to lift
some restrictions based on the new CMS guidelines. We were scheduled to
see him in his room March 17 and 19, but a staff member tested positive
for COVID and we were no longer allowed in the building. We instead had
2 tent visits scheduled for 30 minutes.
Would have things been different if we were allowed to be with him all
this time? Has he given up the will to live because of the current
circumstances or is it just a progression of his illness? We may never
know, but these questions will linger with us for a lifetime.
My family may not personally benefit from any efforts made by you on
our behalf, but I don't want other families to go through this. The
last year has been pure hell. I was hoping with the vaccine things
might change.
These protocols and regulations may have looked good on paper to
prolong life and decrease infection in residential facilities, but the
realities are something all together different. While the protocols may
have prolonged the quantity of life, they has drastically impacted the
quality of life.
I'm sure there will be another virus or health crisis in the future.
It's inevitable. This can not happen again. The complete closure of
these facilities and lack of access to loved ones is cruel and unusual
punishment. Our seniors deserve better.
Sincerely yours,
Rachel Winters
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