Even as we begin to talk about ways to get back to some sense of normalcy over the coming months, individuals with complex care needs — and those dedicated to caring for them — continue to be in danger.
People who are elderly, disabled, or have multiple chronic conditions face a greater risk of developing serious and even deadly complications from COVID-19, and the systemic failures in the U.S. health care system have left the complex care population exposed to additional harms.
Of particular concern is the dual-eligible population, the 9 million people dually eligible for the full range of Medicare and Medicaid benefits. These beneficiaries, who are disproportionately elderly but also include younger people with disabilities, tend to have more underlying conditions than the average Medicare beneficiary.
Not only are they less able to take precautions to protect themselves because of their limited incomes (such as stocking up on food to practice effective social distancing), about half of the dual-eligible population receives long-term care, either in the community at large or a facility dedicated to providing such care, like a nursing home. Thus, they represent a large portion of the 1.3 million people nationwide receiving care in these facilities today.
Under ordinary conditions, long-term care facilities are vulnerable to outbreaks of respiratory illnesses. Infections spread easily among large groups of people living together in confined settings with communal meals and participating in group social activities. Many long-term care facility residents have conditions that make them incapable of practicing the levels of personal hygiene required to stop transmission.
‘Ground Zero for COVID’
The vulnerabilities afflicting the complex care population have been laid bare already by COVID-19 outbreaks in long-term care facilities across the country. As early as February, Life Care in Washington was the first indicator of the challenges that lie ahead for U.S. nursing homes as 129 people — including 81 residents, or two-thirds of Life Care’s population — tested positive for the virus. A total of 37 people have died.
Sadly, this story is not a one-off. Seventy people were found dead of the virus in a New Jersey nursing home. Likely more than one-fifth of all virus-related deaths — more than 10,000 people total — have been linked to nursing homes.
Long-term care facilities “have been ground zero for COVID-19” as CMS Administrator Seema Verma recently said. There are many reasons why this has happened, but the way that these facilities have been incentivized historically only makes the problem worse, especially for the lowest-income and most vulnerable patients that they serve.
Nursing homes have frequently been at the center of a game of “hot potato” for dual-eligible patients. State Medicaid programs are the primary payer of long-term nursing home stays for this population and incentivize these facilities to provide bare minimum services — both through low reimbursement rates and the ways they cover the benefit. The result: Patients are moved to hospitals paid for by Medicare whenever medical issues arise — further, if the patient stays in the hospital for three or more days, the nursing home is eligible for higher Medicare reimbursement for a period of time upon their return to their facility. These actions save state cash-strapped Medicaid programs money and allow nursing homes to receive higher reimbursement.
Even in the best of times, this common practice is bad for patients, but it’s that much more dangerous now. Those facilities that continue doing it unnecessarily put their patients at increased risk. When they don’t, they stand to experience revenue shortfalls. It may be easy to vilify nursing homes — for some facilities, such criticism is warranted — but these actions are indicative of a broken system that needs to be fixed.
Integrated Services
Integration of Medicare and Medicaid services for the dual-eligible population is one of the best ways to eliminate perverse incentive structures that cost the system more money and lead to worse outcomes for people. If Medicaid and Medicare are required to maintain their current level of coverage and act as one program in setting coverage and payment rules for the care of this population, there would be little room to shift costs.
It is difficult to imagine merging two different and large public health insurance programs, but this concept is not new and does not require us to overhaul how all of insurance is provided in this country. We have made significant strides over the last 10 years under both Democratic and Republican leadership.
The Affordable Care Act allowed for the creation of a demonstration where states tested new models that went further to integrate the two programs on a wider scale than ever before. Then recently, a type of Medicare Advantage plan tailored to serving this population — dual eligible special need plans (D‑SNPs) — became a permanent program. These plans are also now required to provide more coordination with Medicaid than ever before.
We still have a long way to go despite these advancements. Too few states make integrated coverage options available to their residents and too few eligible people enroll in them even when offered. Only 10 percent of individuals who are dually eligible for the full-range of Medicaid and Medicare benefits are enrolled in an integrated coverage option. Further, none of these existing integrated programs truly pool Medicare and Medicaid dollars, so cost-shifting has not been significantly thwarted.
Given the dire current conditions, states, hospitals, nursing homes, and other key health care stakeholders need immediate support while they deal with the crisis at hand. That may include additional dollars and increased access to medical supplies, for example. However, these are short-term solutions. Their necessity represents key shortfalls within our existing health care system, especially as it relates to caring for low-income, elderly and disabled individuals.
As we begin to contemplate the next phase of managing this crisis that involves grappling with lessons learned, it is time for leaders to address the systemic failures that are driving many of the problems we are witnessing in nursing homes today and to put solutions to integrate Medicare and Medicaid back on the table.
