States prod nursing homes to take more Covid-19 patients

Maggie Severns and Rachel Roubein

Programs designed to help elderly people with coronavirus are creating a perverse financial incentive for nursing homes with bad track records to bring in sick patients, raising the risks of spreading infections and substandard care for seriously ill patients, according to advocates for the elderly and industry experts.

Coronavirus-positive patients can bring in double or more the funding of other residents. States including California, Massachusetts, Michigan and New Mexico, wanting to relieve pressure on crowded hospitals, are providing extra incentives for nursing homes to accept such patients.

Some homes have been eager for the new revenue, creating coronavirus wings or even converting to all-coronavirus facilities. But the ones most desperate for the money are often among those with low ratings and a history of citations for poor cleanliness or neglecting patients. In Michigan, for example, eight of 20 nursing homes selected by the state government to build wings for coronavirus-positive patients are currently rated as "below average" or "much below average," the two lowest designations, on the Health and Human Services department's five-star nursing home rating scale. One was sued in 2017 by a state watchdog group after a man died in its care.

The fear, advocates say, is that the generous payments designed to help patients will only serve to expose more elderly people to some of the factors that have led to nearly 26,000 Covid-19 deaths in nursing homes, from the rapid spreading of germs to a shortage of protective equipment.

“The places hospitals want to send these Covid-positive patients turn out to be the places least equipped to take them, places that are already the most dangerous facilities in the United States,” said Mike Dark, an attorney at California Advocates for Nursing Home Reform. “These are places that have serious infection control issues, terrible understaffing issues.”

For instance, New Mexico’s first nursing home solely for coronavirus patients, Canyon Transitional Rehabilitation Center, was cited as having issues with infection control during regular inspections in both 2018 and last year, and was fined $13,605 by the federal government last year for a lack of proper procedures that led to a five-minute delay in performing CPR on a resident after he became unconscious.

Nonetheless, Canyon Transitional Rehabilitation Center will receive $600 per bed for housing the patients, more than double the reimbursement rate it received for some residents in the past. In some cases, it will also receive a daily payment for empty beds.

The chief medical officer at Genesis, the for-profit chain that oversees Canyon, said the nursing home "meets or exceeds" the standards needed to help patients, and "staff stays hyper-vigilant and goes above-and-beyond protocols and guidelines from the CDC and others."

In California, a Los Angeles County nursing home that volunteered to be among the initial batch of facilities exclusively accepting coronavirus patients said it would bill $850 per day, according to a letter to insurers obtained by the Los Angeles Times. The home had been cited twice last year for infection control issues during inspections.

Separately, for small assisted living facilities, which have six residents or fewer, the state is offering $1,000 per day for any facility willing to convert into a Covid-positive home, or $30,000 month, according to a letter sent by the state to facilities earlier this spring. Even with the additional medical costs, that’s a significant increase over the median $4,500 cost of assisted living in the state.

In late March, Massachusetts also unveiled a plan to create nursing homes that were singularly dedicated to coronavirus patients. One nursing home started moving patients without the virus out the same week as the announcement. The plan has since been put on hold, after nursing homes participating in the plan found they could not relocate their patients because some turned out to have the coronavirus.

The state has set aside $50 million to pay to nursing homes that set up isolated wings for Covid-19 patients, in addition to other reimbursement the patients will receive.

But half of the Massachusetts nursing homes that have created dedicated wings for Covid-19 patients are either rated “below average” or “much below average” – two-star or one-star -- on the federal scale, according to a review by the advocacy group Massachusetts Advocates for Nursing Home Reform. And two had been designated “special focus facilities” by the Centers for Medicare and Medicaid Services, which put them among the 88 worst nursing homes in the country, the group found.

In Rhode Island, the state is paying two facilities $8,250 per day to serve as coronavirus specialty homes to cover costs related to specialized protective gear, staffing and infection control measures, according to a health department spokesperson. Both of the homes are low-rated: One receiving two stars and one a single star, indicating “much below average.”

Mike Wasserman, a former nursing home company executive and a doctor specializing in the elderly, said allowing facilities with troubled records to handle a large number of coronavirus patients poses huge risks.

“You’re saying facilities that were unable to control the outbreak are now of enough quality to do the hardest job that was ever known to nursing homes, ever,” said Wasserman. And transferring existing residents to different nursing homes or wings could accidentally spread the virus, Wasserman argued.

David Grabowski, an expert in aging and long-term care at Harvard Medical School, said creating Covid-specialty nursing homes is a great idea in theory, but has proven difficult to implement because the best and most qualified nursing homes – the four- and five-star facilities -- are already full and don’t have room to take on more patients.

“There's no way that one-star and two-star facilities for the most part should be doing this unless they can show that there's been a big change in management” or a partnership with a hospital system, he said.

An illustration of the challenges in implementing such plans is Michigan, which selected 20 nursing homes as “hubs” with dedicated wings to care for coronavirus-positive patients after they’ve been discharged from hospitals. But the hubs chosen by the state are of mixed quality: Eight of them are either one-star or two-star facilities. The state gave them $5,000 per bed initially, and an additional $200 per occupied bed every day.

One Michigan home, which is opening up 27 beds for coronavirus patients, Medilodge of Grand Blanc, has been on a special federal list reserved for nursing homes with a record of poor inspections for 13 months. However, the facility has shown improvement, according to an April list of these facilities, which get extra attention from the Centers for Medicare and Medicaid Services.

In 2017, the home was sued by a state-appointed group investigating abuse and neglect after a resident was found unresponsive, and later died – a case that both parties have since dismissed. A spokesperson for the parent company declined to comment.

Lynn Sutfin, a spokesperson for the Michigan health department, said the facilities were chosen for a variety of reasons, including their track record and ability to quarantine patients. The department, along with other state and local officials, are working together to “ensure appropriate safety and infection control practices were in place” for each facility, she said.

Advocates for the nursing home industry say the vastly increased reimbursements are crucial to maintaining adequate care for Covid-positive patients.

“Long-term care providers are putting significant resources toward responding to this crisis, whether through acquiring high-priced personal protective equipment, offering staff ‘hero pay’ and hiring additional help, or in testing residents and staff,” the American Health Care Association, which represents nursing homes, said in a statement. “More support to nursing homes and assisted living communities will be needed, and it requires a collective effort from the public and private sectors to support long term care.”

The Covid-19 patients arriving at nursing homes are usually eligible for Medicare, which pays a significantly higher rate than Medicaid’s long-term care payments for low-income individuals, a main source of revenue for many nursing homes. The federal payments are on top of the state-based incentives for homes to retrofit their facilities for Covid-positive patients, which many states instituted after New York Gov. Andrew Cuomo came under intense criticism for forcing facilities to accept patients from hospitals.

Grabowski, the Harvard public-health professor, said the extra resources are needed to keep the homes disinfected, make sure the staff is properly equipped, and keep well-qualified health workers.

“It is expensive to retrofit a wing or a unit in an existing nursing home,” he said. “It is expensive to pay staff to do this care well, but if we’re going to pay that kind of money we want to make sure we’re paying facilities that are capable of doing this well.”

Nonetheless, the higher reimbursements have yet to pay off for at least one of the two Rhode Island nursing homes that volunteered to house coronavirus patients. After the plan was unveiled, the number of coronavirus infections in the state dropped while labor costs skyrocketed. The home -- a two-star facility -- says it’s losing thousands of dollars every day, the Providence Journal reported.

The other Rhode Island home, Oak Hill Health and Rehabilitation Center, didn’t comment on its finances. But a spokesperson for the one-star facility said it is well-equipped to take care of coronavirus patients; it’s had sufficient protective gear since early March and has trained its staff.

“This has nothing to do with money or the ratings, it had to do with providing care to a population of patients that are in need, and in reality, a population of patients that other skilled nursing facilities did not want to accept,” Jeff Jacomowitz, a spokesperson for the nursing home, wrote in an email.