CMS Statistics Reveal Extent of COVID-19 Impact on Medicare Beneficiaries and Nursing Home Residents

Early statistics and data released by the Centers for Medicare and Medicaid Services (CMS) reveal the extent to which COVID-19 has affected Medicare beneficiaries generally and nursing home residents in particular.

Impact on Medicare Beneficiaries

Regarding the effect of COVID-19 on Medicare beneficiaries in general, CMS made statistics available based on Medicare fee-for-service claims and Medicare Advantage encounters for any treatment or diagnostic setting during the period of January 1 to May 16, 2020 that were received by June 11, 2020.  The data underlying the statistics is based on diagnosis codes relating to COVID-19.  Because there is often significant lag time between the date of service and receipt of a claim relating to that service, CMS cautions against utilizing the statistics for public health surveillance; however, the information nevertheless is useful for looking at the effect of COVID-19 at a given point in time even if the final story won’t be written until many months, if not years, in the future.

Points to note for the time period covered and claims received:

• Medicare beneficiaries account for 326,674 cases of COVID-19, with case rates the highest in population centers on the East Coast. Hospitalizations were also highest in these areas.
• Case Characteristics (all statistics cited below are per 100,000 beneficiaries)
  • Female beneficiaries had a slightly higher case rate (527) than males (508).
  • The number of cases was four (4) times higher among those beneficiaries dually eligible for both Medicare and Medicaid at 1,406 than those covered by Medicare alone at 325.
  • Blacks (1,107) and Hispanics (692) were disproportionately more affected by COVID-19 than Asians (455) or Whites (417).
  • Unsurprisingly, those aged 85 or older (1,140) had a higher case rate than those in other age groups.
  • Beneficiaries with End-Stage Renal Disease (ESRD) were affected at a rate five times higher than those who were aged or disabled.
• Of those hospitalized for COVID-19, 50% had a length of stay of one week or less. Discharge statistics showed that 28% succumbed to the disease, whereas 38% were discharged to home (with or without home health) and 28% were transferred to another facility.

The preliminary statistics and disparities revealed by the underlying data, prompted CMS Administrator Seema Verma, in a blog post, to call for continued transition from the traditional fee-for-service model to a value-based model that holds providers accountable for the outcomes they achieve and incentivizes value over volume of services.

Impact on Nursing Home Residents

Earlier this month, CMS issued two memoranda¹   that dealt with the release to the public of COVID-19 nursing home data derived from reports required to be made by nursing homes to the National Healthcare Safety Network (NHSN), which is administered by the Centers for Disease Control and Prevention, and inspection results for surveys conducted on or after March 4, 2020, which is the date on which the agency announced that it would be prioritizing its survey activities.²   The data reported to date³   reveal the following:

COVID-19 Statistics

CMS is making COVID-19 data reported by facilities through the NHSN portal available to the public in the “Spotlight” section of the Nursing Home Compare website.

• Nursing homes have reported a total of 107,389 confirmed cases and an additional 71,278 suspected cases of COVID-19, accounting for 29,497 deaths.  This represents a death rate of nearly 25% if only confirmed cases are considered and 16.5% if both confirmed and suspected cases are factored in.
• States hardest hit in terms of confirmed cases are primarily those with high population centers on the East Coast, including New York (10,523), New Jersey (10,425), Massachusetts (9,065), and Pennsylvania (9,032), though Illinois (7,964) and California (7,290) also have a high number of cases.
• These same states unsurprisingly also had the highest number of deaths: New York (3,879), New Jersey (2,916), Massachusetts (2,859), Pennsylvania (2,689), Illinois (1,938), and California (1,677).  Despite reporting only 3,632 confirmed cases of COVID-19, Michigan facilities reported 1,670 deaths from the disease.
• When the number of confirmed cases are viewed in light of the average number of cases per 1,000 residents in the state, New Jersey (333.1), Massachusetts (326.4), Connecticut (318.6), Rhode Island (264.8), and Maryland (241.4) lead the nation. Pennsylvania ranks 10^th with 147.8 cases, Illinois is 12^th with 131.2 cases, New York is 13^th with 127.3 cases, and California is 17^th with 88.8 cases.
• When viewed in light of the average number of deaths per 1,000 nursing home residents, Massachusetts has the highest death rate (105.5), followed by New Jersey (101.3), Connecticut (88.2), Rhode Island (70.0), and Delaware (60.7).

Other reporting data, such as COVID-19 cases and deaths among staff, staffing shortages, supply of personal protective equipment, and ventilator capacity are available to search on a facility-by-facility basis.

Inspection Statistics

Inspection results for the period from March 4, 2020 to April 29, 2020 are also available in the “Spotlight” section of the Nursing Home Compare website. Of note regarding the 5,743 inspections conducted according to CMS’s prioritization of survey activities,⁴   only 144 deficiencies were cited for violation of F880, pertaining to infection prevention and control requirements.  All violations, as well as underlying Form 2567 Statement of Deficiencies reports are available for download.

So what do these statistics portend for providers?  Certainly providers still face daunting challenges when it comes to keeping COVID-19 out of their facilities and minimizing the spread of the disease when residents or staff are suspected or diagnosed as having it, particularly as states progress through their reopening phases and restrictions are increasingly relaxed.  And despite the relative lack of deficiencies cited for infection prevention and control requirements during March and April, because nursing homes have been disproportionately affected by COVID-19, they will remain an intense focus for CMS in terms of inspections and enforcement actions.  Specifically, in a June 1, 2020 memorandum, CMS announced that states must complete a focused infection control survey of all facilities by July 31, 2020.  The memorandum also instituted enhanced enforcement protocols with respect to infection prevention and control violations.⁵   But aside from these certainties, the story of the long-term ramifications of COVID-19 continues to be written, one statistic at a time.

[1] See QSO 20-32-NH (June 4, 2020) (COVID-19 matters) and QSO 20-33-NH (June 4, 2020) (nursing home inspections data).

[2] See QSO-20-12-All (Mar. 4, 2020) (prioritizing surveys in response to immediate jeopardy complaints, complaints alleging infection control concerns, statutorily required recertification surveys, revisit surveys, initial certifications, surveys of facilities with a history of infection control deficiencies at the immediate jeopardy level in the past three years, and surveys of facilities with a history of lower level infection control deficiencies, in that order).  See also QSO-20-20-All (Mar. 23, 2020) (further prioritizing surveys to focus on complaint/facility-reported incident surveys and targeted infection control surveys). Because the prioritization of survey activities would skew the inspection domain of Nursing Home Compare and facilities’ Five Star rating, CMS announced that it would be freezing the inspection domain temporarily and making inspection information available on the Nursing Home Compare website.  See QSO-20-28-NH (Apr. 24, 2020).

[3] Statistics are based on reporting as of the week ending June 7, 2020.  While the vast majority of nursing homes have made reports of their COVID-19 related data via the NHSN as required by CMS, a 100% reporting rate has not been achieved to date.  Accordingly, CMS statistics taken from those reports underrepresent the number of cases, suspected cases and deaths attributable to COVID-19.  Providers that do not make timely reports are subject to enforcement actions.  See QSO-20-29-NH (May 6, 2020).

[4] See supra note 2.

[5] See QSO-20-31-All (Jun. 1, 2020).  See also Horowitz, Of Carrots and Sticks:  CMS Seeks Change in Nursing Homes, available at:  https://www.agg.com/news-insights/publications/of-carrots-and-sticks-cms-seeks-change-in-nursing-homes/.