Costly Rehab for the Dying Is on the Rise at Nursing Homes, a Study Says

Nursing home residents on the verge of death are increasingly receiving intense levels of rehabilitation therapy in their final weeks and days, raising questions about whether such services are helpful or simply a lucrative source of revenue.

That is the heart of a new study published in the Journal of the American Medical Directors Association, which found that the practice was twice as prevalent at for-profit nursing homes as at nonprofit ones.

More broadly, the study’s findings suggest that some dying residents may not be steered to hospice care, where the focus is on their comfort.

Although the research is based on a relatively small number of patients in one state, it echoes what federal regulators have found in recent years.

It’s also a fresh reminder that families should keep a close watch on, and ask questions about, the kind of care their relatives are getting in nursing homes.

“Some of these services are being provided in the last week and sometimes on the day of their death,” said Dr. Thomas Caprio, one of the study’s authors. Caprio, who specializes in geriatric medicine, hospice and palliative care, is an associate professor at the University of Rochester Medical Center.

Rehabilitation services — physical, occupational and speech therapy — are “a potential revenue source for these facilities,” he added. “And when the plan of care shifts to hospice care and palliative care, that revenue stream disappears.”

The study examined the level of rehabilitation therapy provided to nearly 55,700 long-term residents at 647 skilled-nursing homes in New York state in the 30 days before they died. The period analyzed was October 2012 through April 2016.

Nearly 14 percent of those residents, or 7,600, got some rehabilitation in the month before they died. Of that group, 2,667 received therapy at high (at least 325 minutes a week) to ultrahigh (at least 12 hours) levels.

Medicare often covers rehabilitation therapy for long-term patients and nursing homes can bill Medicare at the highest rate for ultrahigh levels of treatment.

Among nursing home residents who got therapy, those receiving “ultrahigh levels” jumped 65 percent from 2012 to 2016, to 7.3 percent of those individuals — with most of the rehabilitation concentrated in the last seven days of their lives.

Daniel Ciolek, associate vice president of therapy advocacy at the American Health Care Association, a nursing home trade group, said in a statement that its members had long supported redesigning payment models to be based on patients’ needs rather than the delivery of services.

But he said the group also took issue with the research for trying to “draw broad generalizations from what are very narrowly based study parameters.”

Helena Temkin-Greener, the study’s lead author and a professor at the University of Rochester Medical Center, disagreed.

“You can say it is not such a great number,” she said. “But it is a growing number. And this is just New York, not the whole country — and every year more and more Americans are dying in nursing homes.”

The analysis relied on patient data from the Minimum Data Set, which tracks the health status and other socio-demographic information of patients in all New York nursing homes.

A spokesman for the New York State Department of Health said nursing homes were required to follow their residents’ care plans, which are developed with their doctors.

“If actions taken by a nursing home were to cause patient harm,” the spokesman said, “the department would investigate and take appropriate actions.”

Rehabilitative therapy in nursing homes can provide significant benefits, even for patients who are not expected to recover. Speech therapy, for example, can help patients maintain their ability to swallow.

The study did not analyze the results of the therapy provided. But the researchers said their findings suggested that the “dosage” — or the scope and intensity — might be excessive, perhaps even making patients less comfortable.

Richard Mollot, executive director of the Long Term Care Community Coalition, a nonprofit advocacy group based in New York, said the study’s findings troubled him. He urged nursing home residents, their families and others who worked with them to be vigilant about the appropriateness of the care they receive, whether they believe it is excessive or inadequate.

“Residents should receive therapy and other services that can help them attain, and maintain, their highest practicable well-being,” Mollot said. “However, these services must always be tailored to the personal needs, goals and wishes of the individual.”

Some patient advocates expressed a concern that the potential overuse of therapy by nursing homes to pad profits would hurt efforts to get therapy for people who truly needed it, whether to maintain functions or to prevent or slow their decline.

“We need to be able to keep both perspectives,” said Toby Edelman, senior policy attorney for the Center for Medicare Advocacy. “Nursing facilities are providing more therapy than needed in order to increase their reimbursement, and nursing facilities are not providing appropriate maintenance therapy to residents who need it — at the same time.”

The study found that, broadly speaking, nursing homes with more registered nurses and licensed practical nurses on staff were associated with lower levels of therapy.

The Centers for Medicare and Medicaid Services plans to change the way they pay for many medical services, including rehabilitation therapy, which will no longer be based on the quantity of treatment provided but on a patient’s traits.

But Caprio said the change would not affect how therapy services were billed for the type of patients he and his colleagues studied, who are typically covered by Medicare Part B.

Caprio, Temkin-Greener and their colleagues said their results mirrored what federal regulators, including the Department of Health and Human Services’ Office of Inspector General and the Centers for Medicare and Medicaid Services, have found: that the volume and intensity of therapy provided to residents may be more extensive than warranted.

And despite the study’s being limited to New York, the researchers said they believed the problem could be much greater in others states with less-stringent regulations.

“I would think it is magnified in other states,” Caprio said. “I think this is just tip of the iceberg, really.”