The U.S. regulatory process for skilled nursing facilities needs to be overhauled to focus on outcomes, Seema Verma, the outgoing administrator for the Centers for Medicare & Medicaid Services (CMS), argued in an opinion piece published January 8.
“Despite nursing homes receiving infection control guidance, government-funded testing, training, supplies, staffing, and over $7 billion in additional funding, far too many residents have tragically lost their lives,” she wrote in Newsweek. “Keeping nursing home residents safe despite community spread has proven a lasting challenge. Such struggles did not materialize out of thin air; long before COVID-19 struck, infection control was the most commonly cited infraction in nursing home surveys.”
The U.S. long-term care system “relies too heavily on nursing homes,” regarding them as the default option, Verma argued, and the first goal of any overhaul should be to provide support in home- or community-based settings. But coverage limitations, workforce challenges, and reimbursement rates pose hurdles to these services and limit their availability throughout the U.S., she wrote.
“Nevertheless, nursing home care will always be an important option for people who need a higher level of care, and there is much work to be done to increase quality and safety,” Verma noted. “Nursing homes face a precarious financial situation and the pandemic has exacerbated it. Medicaid is the largest payer of long-term care but its reimbursement rates are often low, resulting in razor-thin or negative margins that make staffing and training difficult.”
That said, Verma stressed making reforms to nursing home reimbursement, rather than increasing funds. She pointed specifically to the fact that “only about 2% of nursing homes’ Medicare reimbursement is tied to quality outcomes,” while Medicaid reimburses nursing homes “on an ineffective per-day basis, regardless of outcomes.”
Verma also criticized the state of regulations, which she characterized as a process-focused “regulatory quagmire finalized in the waning days of the Obama administration” that was inherited by the Trump regime.
Specifically, she focused on the fact that the regulatory system does not focus on the outcomes nursing homes should reach, noting the fact that it was designed more than 25 years ago and is centered on financial penalties without improving quality or the issues it uncovers.
Even before COVID-19, CMS was moving towards overhauling oversight, according to a 2019 Skilled Nursing News podcast with then-CMS chief medical officer Dr. Kate Goodrich. At the time, Goodrich discussed the changes coming to nursing home oversight, with an emphasis on improving the survey process and making strides on infection control.
Verma reiterated those points in the January 8 opinion piece.
CMS is working to use advanced analytics of survey reports, claims data, and information from the Centers for Disease Control and Prevention (CDC) to identify nursing homes that are performing poorly and work with them to fix the problems they face, Verma said.
“Outcome-focused payment must be paired with outcome-focused regulations,” she wrote. “Facilities certainly must be held accountable. They, after all, are ultimately responsible for a resident’s care, but they should be held accountable for the right things; the level of infectious disease in a home is a better measure than the number of months a facility keeps paperwork on file.”