Nursing home patients who receive what is deemed as “ultra high” therapy—at least 720 minutes per week—generate many nursing homes’ largest payments from Medicare. According to a Wall Street Journal analysis of billing records, Medicare’s ultrahigh rate was estimated to be about $560 per day in 2013. The estimate was $445 per day for “very high” therapy of 500 to 719 minutes and $325 for what was deemed the “low” category, 45 to 149 minutes.
The analysis also found that nursing homes gave ultrahigh therapy to patients on an estimated 7% of days they billed to Medicare in 2002, and 54% in 2013. Medicare is mandated to cover up to 100 days of nursing-home care after hospitalization; patients pay for a part of that care in some instances.
Far too many cases have been found in which nursing home patients were given inappropriately intensive therapy for the sake of the financial incentives Medicare provides.
According to Vincent Mor, a Brown University professor of health-services and chairman of the independent quality committee at HCR ManorCare Inc. (one of the country’s largest nursing-home operators), “Playing to the max has a long tradition in health care…[At nursing homes], that tradition is based on the number of minutes of therapy given, so people give therapy up to the max.” Factors that include a trend of sicker patients being admitted to nursing facilities could influence the rise in therapy, as well.
Although rehabilitation therapy in nursing homes can be instrumental to recovery, especially for patients who are very sick, such therapy given to patients who are unresponsive, highly unlikely to improve, or have declined such services, often distressing vulnerable patients. David Grabowski, a Harvard University professor who researches nursing-home expenses, says, “The system really rewards high-intensity care. There are patients being treated who aren’t appropriate.”
A key factor at many nursing facilities is the 720-minute mark. Meaning, Medicare does not pay extra for therapy given beyond 720 minutes, so facilities feel pressure to retain patients for as long as possible, up to 720 minutes. “You heard about it if you went over by even a minute,” says Shawna Pope, a speech therapist who has worked for RehabCare at various facilities.