Finding out the history of a nursing home can be of great value to anyone searching for a facility. It’s like buying a used car — if you know its history then you can be comfortable with your decision.
But it doesn’t work that way with nursing homes because the information available is limited and often not entirely accurate, say the experts we spoke with for this story.
The problem is the outside world rarely is privy to what goes on inside a nursing home.
Attorney Tony Chicotel, lead counsel for the California Advocates for Nursing Home Reform (CANHR), says revelations in an academic study titled “Overbilling and Killing” may be a game changer, though. The two-year study that was published last October used data on nursing home reimbursements to dig deeply into the nursing home industry.
What it found is an industry with serious problems and a rating system that doesn’t always reveal a true picture of the practices inside some — but not all — skilled nursing facilities, or SNFs, in California and the rest of the country.
Accurate reporting on what is happening inside a nursing home or an assisted living facility is often limited to what state or federal investigators uncover. For years it has been a reality that what happens in nursing homes stays in nursing homes.
The challenges in uncovering the truth in nursing home care was the subject of a U.S. Senate Special Commission on Aging hearing in 2023. Its report, entitled “Uninspected and Neglected,” details how Senate investigators found a serious backlog for state nursing home inspections across the entire country.
Another possible source of information on nursing home issues are the residents or families themselves. But these sources of possible information can be stymied by the reporting system, and vulnerable seniors may be reluctant to report problems about the nursing homes they live in.
Even if the inspections are up to date, the number of complaints against a facility are not included in the ratings. Efforts to include those numbers in ratings have gone nowhere, says Chicotel, a longtime advocate for nursing home reform. He has tried repeatedly but “there is no energy for doing that,” he says.
Chicotel believes the “Overbilling and Killing” study will provide important information to anyone considering moving a loved one into a skilled nursing facility.
This academic study is a damning portrait of the nursing home industry. And the numbers come from data provided by the Center for Medicaid and Medicare Services, which foots the bill for nursing homes. What the data and the resulting numbers reveal in some cases is a powerful correlation between over-billing and poor patient care.
The co-authors are Alex Priest of Rochester University and John Griffin, a professor at the University of Texas and the CEO of Integra Med Analytics, which investigates health care fraud and abuse. They found that facilities over-billing Medicare would cut back on expenses and as a result “their patients suffered worse outcomes.”
The integramedanalytics.com website details how they apply statistical techniques across different health care settings to locate fraudulent activities which has led to the creation of the CareWatch online rating system available to anyone.
Priest says their research found that many skilled nursing facilities “are engaging in a variety of potentially fraudulent billing practices, either exaggerating patient conditions or providing unnecessary services.” They found that patients at these SNFs suffer worse health outcomes as companies seek to increase revenues.”
The study reports that nursing facilities have over-billed Medicare by $4.3 billion since the current billing system was implemented in 2019. It also shows there were “3,100 cases of preventable health conditions, 10,800 additional hospitalizations and more than 9,200 additional deaths every year” when the “nursing homes submitting fraudulent claims are compared to other facilities.”
What was uncovered is now publicly available on the CareWatch website. Priest believes the site is a potential lifesaver because “there’s such variation in quality, prospective patients really need to be using all of the data they can to make the most informed decision. It’s an extremely difficult decision to make and it’s even more difficult if you don’t have the right data.”
Currently, the most widely advertised and used rating system to evaluate skilled nursing facilities is a “five-star system” which was created to help consumers by the federal Centers for Medicare and Medicaid Services. It’s supposed to help by allowing users to compare different facilities, simplifying the research for consumers.
It’s similar to the star rating system you might see for movie reviews or restaurants But there is a major deficiency with these ratings, according to Chicotel.
We asked the California Association of Health Facilities, which represents 900 skilled nursing facilities, about the rating system. Raina LeGarreta responded that “while the Centers for Medicare & Medicaid Services’ five-star rating system serves as a benchmark for assessing and comparing the quality of care provided by nursing homes, our members understand the importance of continued improvements to reflect the needs of providing 24/7 care.”
Chicotel maintains that “the biggest flaw in the system has always been that they rely a great deal on self-reported data from the facilities” for the quality of care patients receive. “We have lots of reasons to think that that quality care data is fraudulent from a lot of facilities and it totally skews the rating system,” he says.
It’s not unlike relying on favorable online reviews, but it’s often impossible to find the actual person behind a glowing report. Or being able to substantiate a claim, good or bad. The Times of San Diego found an individual who posted glowing reviews of six locations in California, one in Texas. Each praised the staff, the facilities and their cleanliness. They were all posted in the same time frame.
The “quality of care” problem and the misreporting of what services a patient actually receives was exposed in a now settled lawsuit filed by district attorney offices across California, including in San Diego.
Brookdale Senior Living based in Tennessee “falsely advertised its quality of care” in not reporting “pressure ulcers, weight loss and falls” as well as exaggerating staffing levels, according to the settlement. The company at the time of the filing had 10 skilled nursing facilities in California. Brookdale signed a stipulated judgment to stop “making untrue or misleading statements to the Centers for Medicare and Medicaid Services” in order to manipulate ratings.
Some nursing homes tend to inflate their data so they get five-star quality measures, says Chicotel. “And then on their front door, they say, we’re a five-star facility. What they don’t tell you is, overall, it’s a two- or three-star facility, but on their quality measures, they give themselves five stars.”
LeGarreta of the industry association says the skilled nursing facilities in their organization do recognize that “fraudulent activities by any provider undermines the reputation of the long-term care sector, and can lead to adverse patient outcomes.”
On the CareWatch Star Rating website you will find all of San Diego’s skilled nursing facilities rated. Each facility is given a number grade for rating the staff, health inspections, validated health outcomes and if the facility “prioritizes patient care over reimbursement.”
You’ll find a full range of options for a possible placement. The rating system is easy to understand, with a rating of “1” for poor conditions to a rating of “5” for excellent.
Times of San found seven facilities with poor condition ratings in the San Diego region. This included a facility which last year paid a $15 million dollar fine for negligent care of patients. We attempted to speak with all of the skilled nursing facilities with a poor rating but none responded.
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