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Similar to COVID-19 and Texas Nursing Home Residents Deaths: Is Payor Mix (% Medicaid) Related?
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COVID-19 and Texas Nursing Home Residents Deaths: Is Payor Mix (% Medicaid) Related?
- 1. COVID-19 and Texas Nursing Home Residents’ Deaths: Is Payor Mix (% Medicaid) Related? Annette D. Mulkay SBMI 6313 Scientific Writing
- 2. COVID-19 & Texas Nursing Home Resident Deaths Oct 7, 2020 (Data.CMS.gov) 3603 Nursing Home Residents Deaths Circle size corresponds to number of deaths per 1000 people
- 3. Why this topic? Nursing Homes are the 2nd most regulated industry next to nuclear power plants. So how did we get here?
- 4. Two Payor System Medicare is the money maker (short term care) $500/ day Medicaid is the long term care provider $130/day* *Less than breakeven point
- 5. Operations priorities 1) Rent 2) Management fees 3) Pay staff, food, supplies Money does not stay in the service facility-runs “lean” BUSINESS STRUCTURE
- 6. ANOVA (Analysis of Variance) 2 Tests – 10%, 25% bins What is the relationship? Characteristics of Nursing Homes in Texas (n) Total 1,035 Location Zip code Facilities with Zero Deaths 527 Range of Medicaid Average percent of Medicaid (payor mix) 0-97.3% 69% Range of Medicare Average percent of Medicare (payor mix) 0-99.4% 13% Significance level α = 0.05 Datasets CMS & LTCfocus.org
- 7. Nursing home facilities with the highest percentage of Medicaid patients also had the highest COVID-19 residents mortality rate Most significant at 60%, 70%, and 80% bins (p value of 0.031) Analysis of Means (ANOVA) with 10 % bins
- 8. Nursing home facilities with the highest percentage of Medicaid patients also had the highest COVID-19 residents mortality rate (p value of 0.071—too high) Analysis of Means (ANOVA) with Quartiles (25 % bins) • 50% (549 deaths) • 75% (300 deaths)
- 9. Post-hoc Tukey method should be used to demonstrate variables are significantly different. Summary and Next Steps In a PERFECT WORLD: • Use bins differently • Use more advanced statistical methods • Look at admission assessments— assess how sick before patients/residents arrived at NH • Correlate staffing levels & more quality indicators • Look at population-income levels using US census • Look at finances within facility vs. profits to shareholders
Editor's Notes
- Nursing homes have been the hot spot of COVID-19 deaths in the US and here is Texas’ Nursing Homes Residents’ deaths. The diameter of the circle correlates with increased deaths. As the World Health Organization (WHO) has declared COVID-19 as an endemic, Nursing Homes should consider strategies to plan for controlling this disease
- Researchers have associated COVID-19 NH Resident deaths with race, pre-disposing illnesses, and staffing deficiencies. I’m looking at the operations step before staffing. Nursing homes payor sources. My question is: Are COVID-19 Nursing Home resident deaths related to the payer mix? Let’s follow the money.
- Nursing home services are paid by two primary payors in a "dual-business model“ within the same building. One model is a skilled nursing facility (SNF), or short stay which is paid by Medicare. Medicare typically pays well $500/per patient/per day in Texas. The other model is a long-term care facility (LTC) paid by Medicaid. Medicaid patients are "residents" and live on site. Conversely, Medicaid often pays below the actual cost of services. Texas is notably tight with Medicaid money and pays $130/resident/day ( whereas $300/day is breakeven point). So a facility that has a high percentage of Medicaid residents has a financial liability. The system rewards Medicare patients.
- After 2005, Mom & Pop nursing homes changed to numerous smaller companies in LLCs or (Limited Liability Corporations) and REITs (Real Estate Investment Trust). This way liability and money remain separate. Owner of service corporation = Owner of the land but divided into 2 distinct entities. The operations company runs the nursing home services while investment company manages the Real Estate and the money. Different corporate structures are set up with various “shell corporations” to hedge liability–In Texas, some are up to 8 layers deep of corporate structures. Revenues flow from government money or Medicare/Medicaid to the investment company and bypasses the operations company (facility) Thus, the corporate objective is to make money and not necessarily improve resident care. The result is skimping in staffing ratios,, and supplies. Fines for quality violations are a typical, and allocated as part of the budget
- This retrospective study aimed to ascertain if changes in one factor influence a clinical response. 2 ANOVA tests were performed to evaluate the facilities payor mix (expressed as a % of Medicaid) over Covid19 deaths reported. It is curious to note, there are 527 facilities with ZERO deaths.
- In ANOVA with 10% bins the results show potential trend that may indicate an increased Medicaid mix contributes to a higher count of COVID-19 Nursing Home residents’ deaths. The p-value <.05 supports the hypothesis that payor mix is strongly related to the higher percentage of Medicaid Nursing Home Residents at 60%, 70%, and 80% bins. The thin whiskers indicate a tighter correlation at these noted markers. The funds matter.
- In ANOVA with quartiles. Binned in 25% intervals Unfortunately, the p-value at 0.075 was too high to be statistically significant. However, the visualization of the data was more interesting. These results are like the cited literature as the amount of money that stays within an institution does matter.
- The limitations of this study are that 2017 Medicaid/Medicare data was used for percent Medicaid. Additionally, the COVID-19 data was retrieved in early October, and subsequent COVID-19 Nursing Home Deaths have indeed occurred. While the ANOVA 10 percentile analysis demonstrated significance at 60%, 70%, and 80% Medicaid, Performing a post-hoc test using a Tukey method would help make the results more precise. Further studies should be utilized for current dates. Use bins differently Use more advanced statistical methods But % Medicaid and COVID-19 deaths are not enough information by themselves. Other variables should be considered to substantiate this concept Look at various additional ways to examine this problem admission assessments—assess how sick before patients/residents arrived at NH. Comorbidities would be here. staffing levels & more quality indicators population-income levels using US census finances within facility vs. profits to shareholders More research will enable health care planners and policymakers to identify and diminish future outbreaks in this Nursing Home population. Nevertheless, at present someone is making money while residents and their families suffer (Jagammathan, 2020).