Nursing Homes Push Dying Patients Into Unnecessary and Hazardous Rehab

An alarming study contends that Skilled Nursing Facilities (SNFs) may be pushing dying patients into unnecessary and potentially harmful high-intensity rehabilitation services. The study suggests that nursing homes may be sacrificing patient preferences and comfort for profit.  The study is another in a long list of reasons to plan to Age in Place.

University of Rochester Medical Center researchers noted that the number of residents receiving “ultra-high” rehab services in New York state increased by 65% during the three-year period ending in 2015. Most of those services were delivered to individuals in the last seven days of their lives, according to the analysis of data from 647 nursing homes in the Empire State that was published in the Journal of the American Medical Directors Association.

“These are often sick and frail patients in whom the risks of intensive levels of rehabilitation actually outweigh the benefits,” Thomas Caprio, M.D, a geriatrician and hospice physician at URMC and co-author of the study, said in a statement. “It can increase the burden of pain and exhaustion experienced by patients and contribute to their suffering.”

Researchers studies residents in the Very High (520 minutes per week) to Ultra-High (720 minutes) groupings of rehab services in the last 30 days of life. Authors speculated that rehab levels for the dying may actually be higher in other states with less regulatory oversight. They also acknowledge that some rehab is needed at the end of life, though more commonly of the low or intermediate variety.

The motive for unnecessary and burdensome rehab is profit. According to the report accompanying the study results, "recent reports from the Office of the Inspector General (OIG), the Centers from Medicare and Medicaid Services, and from popular press suggest that the volume and the intensity of rehabilitation therapy provided to residents in US SNFs may be more extensive than is warranted by the residents' care needs." The OIG report from 2010 found that the proportion of seniors referred to ultrahigh therapy (>720 minutes/wk) increased from 17% to 28% during 2006-2008 while the recipients' age, admitting diagnoses, and proportion of seniors with high functional impairment scores remained largely unchanged. The report also noted that for-profit SNFs were more likely to bill for high-intensity therapy compared to not-for-profits—32% versus 18%, respectively.

A 2015 OIG report showed that SNF billings for higher levels of therapy have continued to increase. Between 2011 and 2013, the percentage of ultrahigh therapy days grew from 49% to 57%, whereas residents' characteristics stayed the same. In 2015, SNFs were reported to make a six times or six hundred percent (600%) higher average daily profit margin from providing ultrahigh compared to low therapy intensity. 

According to the study's author's, "[a]t least as concerning as the evidence suggesting some nursing homes may have exploited the prospective payment system to “optimize their revenues” is the claim by the OIG investigators that SNFs billed for therapy levels that were higher than reasonable or necessary, even among the most vulnerable residents." The OIG cited an example of a hospice patient who “received physical therapy 5 days a week for 5 weeks, even though her medical records indicated that she asked that the therapy be discontinued.” Similarly, a 2016 report appearing in the Wall Street Journal quoted interviews with more than 2 dozen former SNF therapists and rehabilitation directors asserting that “managers often pressure caregivers to reach the 720-minute threshold” (required for ultrahigh therapy billing). 

Although the benefits of rehabilitative therapy in nursing homes are well established, pressures to maximize therapy may be inappropriate or even potentially injurious to some patients and may create obstacles to the provision of palliative and end-of-life (EOL) care in nursing homes.  Numerous previous studies have shown that, despite preferences, many residents are hospitalized in the final weeks of life, and receive burdensome treatments that may have few benefits.  Consider the following:

• Potentially avoidable hospitalizations of nursing home residents: Frequency, causes, and costs. J Am Geriatr Soc. 2010; 58: 627–635;
• Site of death among nursing home residents in the United States: Changing patterns, 2003-2007. J Am Med Dir Assoc. 2013; 14: 741–748;
• Hospitalizations of nursing home residents in the last year of life: Nursing home characteristics and variation in potentially avoidable hospitalizations. J Am Geriatr Soc. 2013; 61: 1900–1908;
• End-of-life transitions among nursing home residents with cognitive issues. N Engl J Med. 2011; 365: 1212–1221.

The resident's quality of care may, in such cases, be horrifically impaired. Nursing homes may actually be reluctant to refer their dying residents to hospice so as not to lose the opportunity to maximize a higher Medicare rate by providing rehab.  In other words, preferences and comfort are sacrifices for profit. This conclusion is at least suggested by two separate studies:

• Dying in U.S. nursing homes with advanced dementia: How does health care use differ for residents with, versus without, end-of-life Medicare skilled nursing facility care?. J Palliat Med. 2012; 15: 43–50;
• Influence of hospice on nursing home residents with advanced dementia who received medicare-skilled nursing facility care near the end of life. J Am Geriatr Soc. 2012; 60: 2035–2041.

In one study, nearly one-third of Medicare beneficiaries who were hospitalized received SNF-level care in the last 6 months of life and 9.2% died while on a SNF benefit.  Researchers argue that although such care may be appropriate for some, the receipt of SNF services at the end of life is likely to prevent many patients from receiving hospice and/or palliative care that may be more consistent with their wishes and care needs. A recent study reporting on staff experiences with palliative care in nursing homes noted that staff's desire to develop and provide quality palliative care services may conflict with the nursing homes' need to maximize the provision of rehabilitative therapies. In the words of a staff member, “[t]he goal is to get comfort measure people in therapy. They [residents] get the therapy; they [facility] get higher payment [reimbursement].”

Providers defended their practices to McKnight's Long Term Care News, noting that there is a deliberate system in place to regulate rehab levels. "When individuals request admission to a nursing home, they typically come with documentation on the type of care required. And once they’re at the facility, they must be able to maintain those levels of therapy," Nancy Leveille, executive director of the Foundation for Quality Care, part of the New York State Health Facilities Association, told McKnight's reporter Marty Stempniak. "If their condition is such that they cannot maintain, then nursing homes are unable to make a claim for those rehab minutes," Leveille explained.  "Plus, a significant sample of high-level rehab patients are then audited on a regular basis by Medicare or Medicaid, to validate that the services were appropriate," she added.

“There are checks and balances on the system and there are people who come in with terminal diagnoses and are trying to get back on their feet to be able to get back home or back to a different level of functioning for themselves for quality of life,” Leveille said. “But even within that, if they can’t meet the requirements of ultra-high rehab or any level of rehab, they can’t be scored on that.”

In other words, because billings are approved, the care is justifiable.