Nursing home residents are increasingly spending time in rehabilitation treatment during the last days of their lives, subjected to potentially unnecessary therapy that reaps significant financial benefits for cash-strapped facilities, a study shows.
The proportion of nursing home residents who received "ultrahigh intensity" rehabilitation increased by 65 percent between October 2012 and April 2016, according to research published this month by the University of Rochester. Medicare defines "very high" therapy as almost 9 hours per week, and "ultrahigh" therapy as more than 12 hours per week. Some residents were found to be treated with the highest concentration of rehabilitation during their last week of life.
The study analyzed data from 647 New York-based nursing home facilities and 55,691 long-stay residents who died, with a specific focus on those who received very high to ultrahigh rehabilitation services — including physical, occupational and speech therapy — during the last 30 days of their life.
Such treatments garner the biggest payouts from insurers.
The findings raise questions about financial motives, said Helena Temkin-Greener, the lead author of the study and a professor at the University of Rochester Medical Center Department of Public Health Sciences. Medicare, a federal insurance program, issues hefty reimbursement checks to nursing homes with patients facing the most complex and time-intensive rehabilitation. Temkin-Greener said for-profit nursing homes were more than two times as likely to use high to ultrahigh intensity therapy than nonprofit homes.
"There's a possibility that nursing homes know a patient is approaching end of life, but the financial pressures are so high that they use these treatments so they can maximize revenue," she said. Alternatively, "if it's being driven by a failure to recognize that a resident is approaching end-of-life, then it calls for improving the skills of nursing home teams."
Daniel Ciolek, associate vice president of therapy advocacy at the American Health Care Association, which represents most of the country's for-profit nursing homes, said his organization has long promoted efforts to redesign the payment system to "be based on care needs rather than service delivery."
Associations representing nonprofit nursing homes agreed. "Reimbursement policy should be driven by what it costs to provide high-quality care to all Medicare beneficiaries," said Aaron Tripp, the director of long-term care policy and analytics at LeadingAge, an organization that represents more than 2,000 nonprofit nursing homes.
The study of New York facilities doesn't bode well for how nursing homes throughout the U.S. are treating dying residents, given that most states have less stringent nursing home regulatory oversight than New York. "This is a nationwide problem," said Paul Ginsburg, director of the USC-Brookings Schaeffer Initiative for Health Policy.
Rehabilitation therapy has proved to be incredibly beneficial to patients when properly prescribed, Temkin-Greener noted, but with those approaching death, high-intensity treatment might be preventing staff from providing more appropriate end-of-life care, such as hospice or palliative care. It may also be accelerating residents' decline.
There's one particular piece of data from the study, she said, that points toward nursing homes seeking to profit from vulnerable residents. "If ultrahigh therapy is good for patients at end of life, why are only for-profits using it?" she asked. "These people are using high-intensity services without justification."
Forthcoming Medicare payment and policy changes for skilled nursing facilities may help. Starting Oct. 1, 2019, payments will be determined based on a patient's condition and health needs rather than on the amount of care provided or the intensity of treatment. The Medicare Payment Advisory Commission, an independent U.S. federal body, applauded the decision.
