LTC Bullet: Treasure Trove of LTC Provider and User Data

Wednesday, March 20, 2019


LTC Comment: Who’s getting what long-term care where? Answers after the ***news.***

*** THE 19TH ANNUAL INTER-COMPANY LONG-TERM CARE INSURANCE CONFERENCE convenes next week (March 24-27) in Chicago. Check out the program here. Damon and I will be there. Our next LTC Bullet will be a virtual visit to the conference giving those of you who do not attend a sense of what it was like, a summary of the sessions we attend, and some analysis. ***

*** MY MILLION DOLLAR MOM: A showing of Ross Schriftman’s film is on the ILTCI’s agenda for March 25th. Well worth a viewing. Contact Ross Schriftman, Author, Screenwriter, Producer, LTCi "Producer" and Dementia Advocate at 215-682-7075 or ***

*** More ILTCI news: This just in from Claude Thau: “I hope you can attend our Range of Exposure (ROE) session (Sunday, 2 to 3:30 pm) at ILTCi.  Our ROE tool helps advisors more easily engage clients in productive long-term care planning.” Click for more information. *** 



LTC Comment: Ever wonder exactly how many people are receiving what kind of long-term care in which venues? We refer you today to Long-term Care Providers and Services Users in the United States, 2015–2016 by Lauren Harris-Kojetin, Ph.D., Manisha Sengupta, Ph.D., Jessica Penn Lendon, Ph.D., Vincent Rome, M.P.H., Roberto Valverde, M.P.H., and Christine Caffrey, Ph.D.

According to its Abstract: “This report presents the most current national results from the National Study of Long-Term Care Providers (NSLTCP) conducted by the National Center for Health Statistics (NCHS) to describe providers and services users in five major sectors of paid, regulated long-term care services in the United States.”

We’ll share some highlights followed by our comments below, but if you would like to see how two of its authors summarized the report’s findings, with charts and tables, check out this slide deck from a presentation by Harris-Kojetin and Lendon to the LTC Discussion Group on February 21, 2019.

NCHS Report: “In 2016, about 65,600 paid, regulated long-term care services providers in five major sectors served over 8.3 million people in the United States.” (p. 1)

LTC Comment: Wow, that’s 2.5% of the U.S. population of all ages receiving LTC services already. Where?

NCHS Report: “Long-term care services were provided by 4,600 adult day services centers, 12,200 home health agencies, 4,300 hospices, 15,600 nursing homes, and 28,900 assisted living and similar residential care communities (Appendix III, Table V).” (p. 1)

LTC Comment: So, there are nearly twice as many ALFs and RCFs as SNFs. Assisted living came out of nowhere starting in the 1980s to offer a more desirable care venue than Medicaid-financed nursing homes, but only for people able to pay privately. Who goes where?

NCHS Report: “In 2016, there were an estimated 286,300 current participants enrolled in adult day services centers, 1,347,600 current residents in nursing homes, and 811,500 current residents living in residential care communities. In 2015, about 4,455,700 patients were discharged from home health agencies, and 1,426,000 patients received services from hospices (Appendix III, Table VIII).” (p. 1)

LTC Comment: Interesting, while there are around twice as many ALFs as SNFS, the assisted living facilities (and other residential care facilities) have only about 60 percent as many residents as nursing homes do.

NCHS Report: “The majority of home health agencies, hospices, nursing homes, and residential care communities were for profit, while a minority of adult day services centers were for profit (Figure 4). The majority of nursing homes and residential care communities and a minority of adult day services centers were chain-affiliated (Figure 5).” (p. 2)

LTC Comment: Evidently, it’s hard to make a profit offering adult day services. Otherwise, we’d see more companies and chains doing so. Conclusion: adult day services are available because government pays for them and not because consumer demand insists on them.

We often see claims that chain-affiliated, for-profit care facilities provide deficient care compared to non-profit facilities. But that’s not because they are for-profit or non-profit. It’s because for-profit facilities serve more Medicaid recipients for whom they receive reimbursement at less than the cost of providing the care. You can’t expect Ritz Carlton care at Motel 6 rates.

NCHS Report:  “At least one-quarter of services users in each of the five sectors had Alzheimer disease or other dementias, arthritis, heart disease, or hypertension (Figure 24). However, the prevalence of these and six other reported diagnosed chronic conditions varied widely between sectors.” (p. 2)

LTC Comment: Check out the detail in Figure 24 and you’ll find Alzheimer’s Disease and depression are most common in nursing homes whereas arthritis, heart disease, and especially hypertension prevail in home health agencies. Residential care communities have relatively high occupancy by people with each of those ailments.

NCHS Report: “Fewer adult day services center participants needed assistance with four of six activities of daily living (ADLs; bathing, dressing, toileting, and walking or locomotion) than services users in other sectors (Figure 25).” (p. 2)

LTC Comment: Well, yeah! How many adult day care centers would be equipped to handle visitors needing help with four or more ADLs?

NCHS Report:More residential care residents had falls compared with adult day participants and nursing home residents.” (p. 2)

LTC Comment: Makes sense. You’re less likely to fall out of a wheel chair or bed than from walking, which residential care residents are more apt to be able to do than nursing home residents.

NCHS Report: Short-stay (less than 100 days) [nursing home] residents differed from long-stay (100 days or more) residents by age and sex, and in the prevalence of numerous diagnosed conditions, overnight hospital stays, and falls (Appendix III, Table IX).”

LTC Comment: There are more long-stay nursing home users (794,000) than short-stay (606,800) users. Short-stay users are more likely to be under age 65 compared to long-stay users (18.6% vs. 14.9%); less likely to be women (60.3% vs. 67.9%); less likely to have Alzheimer’s Disease (36.7% vs. 58.9%); more likely to have an overnight hospital stay (23.8% vs. 8.7%); but less likely to fall (13.5% vs. 19.1%). Unfortunately, Appendix III, Table IX doesn’t tell us the short vs. long stay break out for “Medicaid as payer source,” the cell for which is blank.

NCHS Report: “Average length of stay among all residents is 485 days; 43% of residents are short-stay and 57% are long-stay.” (Footnote 1 of Appendix III, Table IX, p. 78)

LTC Comment: Now this is fascinating. The average length of stay is 1.3 years (485 days) but with 43 percent of residents staying less than 100 days dragging the average way down, we must conclude that the 57 percent of residents staying 100 days or longer must be staying much, much longer than 485 days in order to bring the average up to that level.

Why does this matter? First, long-stayers in nursing homes tend to be older women with Alzheimer’s who are prone to fall and who mostly rely on Medicaid. They are among the most expensive recipients of Medicare and Medicaid, the so-called “dual eligibles.” CMS reports that 61.8 percent of nursing home residents rely on Medicaid as their “primary” funding source. But that includes both short and long stayers. So when you consider that there are more long-stayers than short-stayers and that long-stayers stay much longer than short-stayers, you must conclude that long-stayers account for a far greater proportion of total patient days than the percentage of all residents with Medicaid as primary payer.

So what? Well, it’s bad enough that over 3/5 (61.8 percent) of nursing home residents generate Medicaid reimbursements at less than the cost of care, but when you realize that nursing homes receive less than the cost of care for an even higher percentage of total patient days, you can fully recognize just how damaging Medicaid dependency is to the ability of nursing homes to provide quality care.

What proportion of total patient days does Medicaid touch with its low reimbursements? The National Investment Center’s latest “Skilled Nursing Data Report” for Q4 2018, covering data from January 2012 through December 2018, says the figure is 66.6 percent. That’s higher than 61.8 percent of residents with Medicaid as primary funding source, but not nearly as high as one would expect it to be based on the analysis immediately above. That’s a paradox that needs to be researched.

Why? Because the same NIC report indicates that Medicaid reimbursement as a proportion of total nursing home revenue has increased from around 47 percent in 2012 to 50 percent in 2016 whereas private-pay revenue has declined from 12 percent to 8.2 percent. Inasmuch as private payers pay half again as much as Medicaid on average, this trend toward Medicaid and away from private pay, which has been going on since private-pay was around 50 percent in 1970, is potentially devastating for the financial viability of nursing homes.

Closing LTC Comment: Kudos to the National Center for Health Statistics (NCHS) for producing the National Study of Long-Term Care Providers (NSLTCP) and publishing this report. As disclosed to the aforementioned meeting of the LTC Discussion Group, NCHS plans to expand and refine this survey and the report in the future. We’ll stay tuned.