‘Plow It Down’: Nursing Home Operators, CMS, Insurers Must Think Bigger to Fight COVID-19 Tide

Over the past few weeks, we’ve seen the federal government rapidly dismantle the dense scaffolding of rules and regulations that had been built over the course decades, all in the name of fighting the novel coronavirus.

Ideas once unthinkable — doctors providing consultations over Skype without fear of violating HIPAA, a blanket freeze on the three-day stay rule for Medicare skilled nursing coverage — are the new battlefield reality as providers fight to keep people safe amid a pandemic without precedent in modern memory.

It’s a good start. At this time, doctors and nurses should be singularly focused on caring for the most vulnerable people without fear of compliance repercussions.

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To be sure, anyone deliberately providing substandard care or neglecting the gravity of this situation should be punished to the fullest extent of our laws. But as long as there are good-faith providers and caregivers on the front lines — of which there are untold millions — they should be allowed to do everything they can to keep our elderly both alive and comfortable.

Just two weeks ago, all of this would have seemed like complete fantasy. Telehealth providers have been fighting for years to ease restrictions on Medicare coverage for remote visits, regardless of where people live; the Centers for Medicare & Medicaid Services (CMS) erased the rules with the stroke of a pen.

Stakeholders in various niches of the post-acute and long-term care industry have lobbied for the erasure of the three-day stay rule, which many argue is outdated in a world where nursing homes can provide the kinds of services that decades ago only hospitals could; CMS again made it go away overnight.

So if the government can do all that in just about a week, what’s ahead? And how can post-acute and long-term care operators look beyond today to the needs of their residents weeks and months from now, when the crisis could be even deeper than it appears right now?

Anne Tumlinson, CEO of consulting firm ATI Advisory, believes it’s time for the government, managed care plans, and post-acute care operators to think bigger.

“There’s a lot more in that regulatory structure that just needs to be wholesale waived,” Tumlinson told SNN during a Thursday afternoon interview. “CMS just needs to plow it down for right now, because hospitals don’t have time parse through — they just need to be able to get people out.”

The supply of hospital beds will continue to dwindle as the crisis unfolds, placing a huge premium on free space to care for COVID-19 patients. The three-day stay waiver was in part intended to solve that problem by allowing SNFs to directly admit residents without the coronavirus, thus reserving prime hospital space for COVID-19 cases that require the most acute levels of care.

But at least as of last week, Medicare Advantage plans were still requiring prior authorizations for transfers to post-acute facilities, a factor that Tumlinson said was hampering what really should be happening on the ground: specialized hospital coordinators sending patients to the right post-acute setting like a field marshal, without needing to wait for approval.

“They aren’t going to be able to do what they need to do, as quickly as they need to do it, if you’ve got all these managed care companies and CMS rules standing in the way — as they are right to do in normal times,” Tumlinson said. “But this way, way not normal.”

As access to testing expands and more people are likely diagnosed with COVID-19, Tumlinson and her team posit that some long-neglected parts of the post-acute and long-term care continuum should be given a second look: inpatient rehabilitation facilities (IRFs) and long-term acute care hospitals (LTACs).

Those settings have been relegated to the background of the continuum in recent years, as SNFs have stepped up to provide a similar level of care at a lower cost. Back in the spring of 2018, Sabra Health Care REIT (Nasdaq: SBRA) CEO Rick Matros referred to the LTAC in particular as a fading asset class, noting that the typical nursing home had become more akin to a hospital step-down unit.

But the nation still has 378 LTACs and 1,110 IRFs, according to ATI Advisory’s count, and many of them are located in dense clusters of existing acute and post-acute care sites.

Amid increasing concerns about shortages of crucial ventilators, Tumlinson believes that it’s time for governments and providers to look at ways to take advantage of this existing infrastructure. To be clear, ATI Advisory — along with many other big-picture thinkers — is not recommending that these facilities accept COVID-19 patients, as such a move would put vulnerable long-term residents at severe risk for infection and death.

But if some of these buildings could somehow be cleared and turned over to coronavirus care, it could ease the burden on the entire post-acute spectrum.

“We are not suggesting that they should start taking COVID patients,” Tumlinson said. “What we’re saying is, in the event that we do really have an even bigger emergency than we can even imagine, we should start to look to some of these sites as centers [of care].”

On the skilled nursing level, Tumlinson also highlighted the importance of reducing readmissions in the long-term care setting — particularly by hammering home the need to skill in place whenever possible.

Earlier this month, ATI Advisory released a comprehensive set of data on health care utilization across senior living settings, determining that nursing home residents have an average hospital admission rate of 0.68 per year — or, put another way, 680 of every 1,000 nursing home residents will be admitted to a hospital in 2020.

Part of the issue is that frontline staff are simply accustomed to sending residents to the hospital when they’re sick. But in an emergency situation where hospitals are overrun, and an acquired COVID infection could spell a death sentence, long-term care facilities need to do what they can to treat in place.

“They’re obviously focused on: how do we keep our long-stay residents safe from COVID?” Tumlinson said. “But a key strategy is: How do we keep them out of the hospital when we’re so used to doing that?”

Expanded telehealth access is a good first step, and operators that have launched or joined Institutional Special Needs Plans (I-SNPs) may also have a leg up: Because I-SNPs, a special kind of Medicare Advantage plan for nursing home residents, require operators to assume the cost of hospital transfers, many of those providers have invested in advanced practitioners who can treat patients in place.

But no matter what bold action health care providers and the government take over the coming weeks, many of the barriers that have been broken — particularly around telehealth access — may never come back up. And as long as providers are laser-focused on patient care, that can only be a weapon for good in the tough times ahead.

“We’re going to be fighting this virus — and certainly among the nursing home population — intensively for the next year and a half, if not two years,” Tumlinson said. “So this is going have to be a permanent part of the toolkit.”

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