TRENDS IN LONG-TERM CARE (Salmonella) MONDAY, DECEMBER 14, 1970 U.S. SENATE, SUBCOMMITTEE ON LONG-TERM CARE, SPECIAL COMMITTEE ON AGING, Washington, D.C. The subcommittee met at 9:30 a.m., pursuant to call, in room 3110, New Senate Office Building, Senator Frank E. Moss (chairman) presiding. Present: Senators Moss and Young. Staff members present: Val Halamandaris, professional staff member; John Guy Miller, minority staff director; and Peggy Fecik, clerk. OPENING STATEMENT BY SENATOR FRANK E. MOSS, CHAIRMAN Senator Moss. The subcommittee will come to order. This is a continuation of a hearing begun by this Subcommittee on Long-Term Care into the facts surrounding the outbreak of salmonella in the Baltimore nursing home some months ago. The long period between the earlier hearings and this one has been necessary because of an investigation we have asked for, and, of course, because of the recess of the Congress. It is rather late in this session of the Congress, but we did want to complete our record so that the committee could determine what sort of a report it wanted to file and whether any legislation was indicated to meet the problems that have been identified in this particular instance. I have a rather lengthy opening statement, but I will forego the temptation to read it in its entirety. I will ask that it be placed in the record in full and I will offer a summary of my statement. On the completion of our August 19th hearing, I asked the General Accounting Office for a limited audit defining the three questions for investigation in four Maryland nursing homes. These nursing homes were Bolton Hills, Harbor View, Forest Haven, and the Gould Convalesarium. The questions considered were: Do nursing home administrators buy food at a low price and charge Medicare or Medicaid a higher price representing food purchases? Second, have nursing homes collected, or attempted to collect, from Medicare and Medicaid for periods after a patient's death? Third, do physicians having responsibility for nursing home patients sign death certificates without ever having viewed the bodies? The report of the GAO,1 which I will try to summarize, first concluded that in order to buy food for a low price and charge Medicare or Medicaid a higher price, operators would have to alter receipts or be in collusion with food vendors. No altered receipts were found by GAO. The possibilities of collusion were not examined. GAO discovered 39 instances in its limited audit where the four nursing homes named had collected from Medicaid for periods after the patient's death. Most involved the home billing Medicaid for a whole month even though the patient had died during the month. Most of these were discovered by the State. In the course of this audit, GAO discovered that there were duplicate payments made to nursing homes under Medicare and Medicaid. GAO had already marked duplicate payments as a serious problem in its July 1970 audit of California nursing homes. Commonly, Medicare rejected a claim, which was submitted then to Medicaid which paid it, whereupon Medicare reconsidered and paid a second time. GAO notes that the States must rely on nursing home operators to notify the State upon receiving duplicate payments. In my view, this is hardly acceptable. GAO disovered that Medicaid audits were not being conducted in Maryland, citing this as significant, since Maryland reimburses on actual cost plus a profit of 10 percent, up to a maximum of $16 a day. In the 3 years from fiscal 1967 through fiscal 1969, only two Medicaid audits were conducted and these were at the same nursing home. Lastly, GAO confirmed my worst fears when it says, "Our examination revealed that it was not an uncommon practice for Maryland physicians to sign death certificates, without first viewing the bodies of patients who had died in nursing homes." The death certificates of 322 people in the four nursing homes were examined. Eighty-nine bodies had been viewed, 50 were not, and 183 did not indicate one way or another. The physician signing 110 of these 183 certificates stated he generally did not view the bodies. Physicians argued it was unnecessary and impractical to view the bodies of those dying in nursing homes, that the nursing staff was capable of ascertaining death. With all due deference to the medical profession, it appears clear that physicians have deserted the nursing home, and that the medical decisions from administering drugs to ascertaining death are falling more and more on the nursing staff. By staff, I mean the aides and the orderlies, the most overworked and underpaid members in our health care system. This is true, because a registered nurse spends most of her time in paperwork, in an effort to aid collection of funds. The trend is unacceptable; it offends my sense of justice. We owe our ill elderly more than this. I invite discussion of these questions today. (The opening statement referred to follows:) OPENING STATEMENT BY SENATOR FRANK E. Moss, CHAIRMAN On July 26 and the days following, a few ordinarily innocuous Salmonella bacteria multiplied themselves into an epidemic claiming the lives of 25 residents 1 See digest of report app. A, item 2, p. 862. of a Baltimore nursing home. From every corner of the land there came outrage and concern as the Nation remembered in death those old and ill citizens it had forgotten in life. This great tragedy has caused at least three forums of public inquiry to be convened. This Committee held a hearing on August 19, which was followed by that of the Maryland Medical Society and the State's blue ribbon panel. Still the elusive questions remain: What was the cause of the Salmonella outbreak? Like so many other difficult questions these will probably go unanswered no matter how many panels of inquiry we convene. There are, however, other questions which emerged from our hearings, and they are National in scope, not solely confined to Maryland. These broad questions include: Are nursing home standards adequate? Does our procedure for the licensing of nursing homes need to be revised and strengthened? How effective are nursing home inspections? Are Federal standards being enforced by the States? Are there duplicate payments to nursing homes under the two Federal programs-Medicare and Medicaid? What is the role and responsibility of the physician with regard to the nursing home? To throw some light on these questions and others I asked the Comptroller General of the United States and the General Accounting Office for a limited audit based on a sample of four Maryland nursing homes. These nursing homes were: The Gould Convalesarium, Forest Haven, Bolton Hills and Harbor View. The specific issues that I asked the GAO to study were as follows: Do nursing home administrators buy food at a low price and charge Medicare or Medicaid a higher price representing food purchases? Have nursing homes collected or attempted to collect from Medicare and Medicaid for periods after a patient's death? Do physicians having responsibility for nursing home patients sign death certificates without ever having viewed the bodies? Taking these questions one at a time, GAO concluded that at least on the basis of this limited audit, there was no evidence of nursing homes paying one price for food and charging Medicare or Medicaid a higher price. GAO states that since in Maryland both Medicare and Medicaid reimburse for actual costs, for nursing homes to indulge in this type of cheating they would have to alter receipts or collusion would have to exist between the nursing home operator and the food vendor. GAO's audit did not reveal any alterations. The collusion question was not considered. In the process of this inquiry GAO also discovered that Hospital Cost Analysis Services, Inc. a nonprofit corporation under contract with the State Department of Health, to audit and analyze nursing homes' cost under the Federal Medicaid program "was not making audits on a regular basis. "For example," the report said, "during the 3 year period from fiscal year 1967 through 1969, Analysis Services had made only two audits of nursing home costs under the Medicaid program. These were made at the same nursing home in conjunction with audits under the Medicare program." The report states that the reason given GAO for this failure was that "sufficient State funds were not available to finance these audits." The report continues, "We believe that when payment rates are based on actual cost as reported by nursing homes, periodic audits by an independent source are an essential control over cost reporting." On the question of nursing home operators attempting to collect payments from Medicare and Medicaid for periods after the patient's death, GAO "identified 39 instances in which payments had been made under the Medicaid program for nursing home care after the deaths of patients. In 34 of these cases the nursing home billed Medicaid for a full month even though the patient had died during the month." GAO indicates of the total of 39 overpayments discovered in the four studied nursing homes 36 had been discovered by State employees and were adjusted. In examining this question GAO discovered that six duplicate payments amounting to $2,000 were made to the four nursing homes. This occurred when claims rejected by Medicare were submitted to Medicaid for payment. Following payment from Medicaid, the other Federal program Medicare reconsidered and also made payment. Twenty-seven instances were found where Medicaid had paid claims after rejection by Medicare. Medicare had subsequently reconsidered and paid in six of these cases and had approved but not yet paid four more of the claims. The State Medicaid official candidly informed GAO that "program officials must rely on the nursing homes to notify them of duplicate payments." The last question of whether physicians view bodies in nursing homes before they sign the death certificate came in for some substantial discussion at our last hearing when it was disclosed that in at least four instances physician did not view the bodies in the Gould home before signing death certificates and that few of the certificates even listed Salmonella as a cause or contributing cause of death. This raises the larger question of physicians' medical duties in nursing homes. It has been my suspicion that physicians simply don't get involved. Our Senate hearing and the State's hearing is replete with references to physicians prescribing drugs for their patients over the telephone during the early days of the Salmonella epidemic. Few physicians felt the need to come quickly to the home to see their patients. Presumably, had physicians viewed the bodies of those in the Gould home they would have become suspicious and asked for immediate tests. The result perhaps would have been an earlier isolation of Salmonella as the cause of death and the death certificates would have not been bare of the word Salmonella as they were. The report from GAO supports my worst fears when it says: "Our examination revealed that it was not an uncommon practice for Maryland physicians to sign death certificates without first viewing the bodies of patients who had died in nursing homes." GAO reports that such practice is not illegal or considered unethical in Maryland. GAO examined the certificates of 322 Medicare and Medicaid patients that had died at the four nursing homes. The records indicate that 89 bodies had been viewed by the signing physician, 50 were not and that the remaining 183 certificates do not indicate whether the bodies were viewed or not. GAO interviewed the physicians who had signed 110 of the 183 death certificates which did not state whether the physician had viewed the bodies. He stated that he generally did not view the bodies. The consensus of the 17 physicians interviewed by GAO was that it was either impractical or unecessary to view the bodies of all patients who died in nursing homes and that the skilled nursing personnel in nursing homes were technically qualified to determine that a patient was dead and to note any unusual developments, other than the illness for which the patient was being treated, which might have caused the death. In a survey of 305 death certificates from Baltimore County (exclusive of Baltimore city) GAO concluded that this same practice prevails outside of the scope of nursing homes. "In the Baltimore area it is not uncommon practice for a physician to sign the death certificate without having viewed the body." With all due deference to the Medical profession and the demands on their time and energies I cannot help but state my extreme concern about this practice. I see every evidence that the medical care in our nursing homes is more and more province of the nursing staff. I underline that Federal Regulations require only one Registered Nurse on the 8 a.m. to 4 p.m. shift and allow Licensed Practical Nurses to supervise for the other two shifts. From my experience the bulk of the time of these nurses is spent with paper work designed at insuring collection of funds. Generalizing once more, the remainder of their time is allocated to supervision so that it is rare for the R.N. to tender services to patients. This means that this responsibility is falling more and more on our nurse's aides. The nurse's aides are perhaps the most overworked and underpaid group of people in the United States. Most of them make only the minimum wage given the demands of the job. It takes real dedication or the lack of other employment opportunities to keep a person in such a position. It appears evident that it is the nurse's aides who-more and more-will be tendering the medical care in nursing homes from giving drugs (although the regulations cite this as the duty of the R.N.) right down to ascertaining that the patient has died and stating the causes for such death. This practice is less than acceptable; it highly offends my sense of justice and fundamental decency. Surely we can do better. |