“Cab Ride to Tribeca,” Thomas Hawk

October 12, 2018; New York Times

“Nursing home residents on the verge of death are increasingly receiving intense levels of rehabilitation therapy in their final weeks and days, raising questions about whether such services are helpful or simply a lucrative source of revenue,” reports Tara Siegel Bernard in the New York Times. The practice, she notes, was twice as prevalent at for-profit nursing homes as nonprofit ones.

Such are the main findings, Bernard writes, of a study authored by four professors from the University of Rochester School of Medicine, published in the Journal of the American Medical Directors Association. “More broadly,” Bernard adds, “the study’s findings suggest that some dying residents may not be steered to hospice care, where the focus is on their comfort.”

The fact that the study found this practice to be twice as common at for-profit nursing homes than non-profit nursing homes is not surprising. As NPQ’s Karen Kahn wrote earlier this year, “Multiple studies over the last two decades indicate that for-profit ownership of nursing homes, particularly for-profit chain ownership, correlates with substandard care.” Unfortunately, as Kahn notes, “nonprofits own less than one in four nursing homes, while for-profits control nearly 70 percent. (The remaining five to six percent are government facilities.)”

One reason nonprofits fold is because margins are slim—and nonprofits are more likely to provide needed care, even if margins are inadequate. As NPQ noted a couple of months ago, the result is that often nonprofits are acquired by for-profits, which may be more willing to cut staffing ratios—or, as the Rochester study suggests, raise income by providing services with greater margins, even if the benefit to patients is limited.

Bernard cautions that the study only examines New York state patients. Still, she notes, the findings are consistent with those of federal regulators. “Some of these services are being provided in the last week and sometimes on the day of their death,” Dr. Thomas Caprio, one of the study’s authors, tells Bernard. Rehabilitation services—such as physical, occupational, and speech therapy—are, Caprio says, “a potential revenue source for these facilities. And when the plan of care shifts to hospice care and palliative care, that revenue stream disappears.”

The study sample size may be modest in scope, but it did look at 55,700 long-term residents at 647 skilled-nursing homes in New York State in the 30 days before they died between October 2012 through April 2016.

“Nearly 14 percent of those residents, or 7,600, got some rehabilitation in the month before they died,” Bernard writes. “Of that group, 2,667 received therapy at high (at least 325 minutes a week) to ultrahigh (at least 12 hours) levels.” Medicare, Bernard adds, “often covers rehabilitation therapy for long-term patients, and nursing homes can bill Medicare at the highest rate for ultrahigh levels of treatment.”

According to the study, patients receiving more than 12 hours of rehabilitation jumped 65 percent from 2012 to 2016, to 7.3 percent of the group “with most of the rehabilitation concentrated in the last seven days of their lives.”

Rehabilitative therapy, Bernard notes, can benefit some patients who are not expected to recover. “Speech therapy” she notes, “can help patients maintain their ability to swallow.” Still the Rochester researchers say that often high-levels of therapy near the end of life may be excessive and can make patients less comfortable.

Toby Edelman, a senior policy attorney for the Center for Medicare Advocacy interviewed by Bernard, notes there are two problems: “Nursing facilities are providing more therapy than needed in order to increase their reimbursement, and nursing facilities are not providing appropriate maintenance therapy to residents who need it.”

While the study was limited to New York, the problem might be worse in less-regulated states. “I would think it is magnified in other states,” says Caprio. “I think this is just tip of the iceberg, really.”—Steve Dubb