Quality, Medicaid and Covid: An Interview with Dr. Tamara Konetzka

Regulation | January 07, 2021 | by Jill Schumann

Dr. Tamara Konetzka, Professor, Dept. of Public Health Sciences, The University of Chicago Biological Sciences joined the LeadingAge Coronavirus Update Call on January 7, 2021.

Dr. Tamara Konetzka, Professor, Dept. of Public Health Sciences, The University of Chicago Biological Sciences joined the LeadingAge Coronavirus Update Call on January 7, 2021. She answered questions from Ruth Katz and from callers.

(Listen to the interview here.)

Q: We would like to hear what you have learned through your research about the relationship between quality measures/ star ratings and COVID-19 outbreaks and deaths in nursing homes?

A: We did a study early in this pandemic when data was limited. We looked at the likelihood of COVID-19 cases as that related to quality star ratings, and we found no meaningful relationship. Since then, we have built more sophisticated models and looked at more nuanced variables such as staffing ratios. We continue to find that there is not a meaningful relationship between the quality elements of star ratings and COVID-19 outbreaks, the size of outbreaks, or the number of deaths. We also found no relationship between histories of infection control violations and COVID-19 cases and deaths. By far the greatest predictor of COVID-19 is community spread. Another variable that makes a difference is the size of the facility – there are more people in and out, so transmission is higher. When asked< What can nursing home improve related to COVID?” I respond, “That is the wrong question.” A better question is, “What can the wider community do to better tamp down community spread?”

Q: Does this research tell us something about the star rating system?

A: I sit on a panel that advises CMS regarding the star rating system. There is some face validity to the system, but there are issues and challenges as well. The lack of a relationship to COVID-19 does not mean the star ratings are bad. This coronavirus is a different kind of challenge.

Q: What have you learned about the relationship between the percentage of Medicaid in the nursing home and the presence and devastation of COVID-19?

A: Medicaid can be a proxy for resources, given Medicaid rates. As we have moved from the spring, to summer, to fall and winter, the percentage of Medicaid is increasing in importance with greater potential for more cases and deaths. Medicaid rates are a longstanding problem many of us have worried about. Reforming the way we pay for long term care is important. Facilities that are largely reliant on Medicaid will have more difficulty fighting COVID-19 without more resources.

Q: Speaking of more resources, what is your thinking about the incentive payments in the Provider Relief Fund program?

A: If research connecting actions nursing homes are taking and the of level of COVID-19 is not strongly correlated, what are we rewarding? The good outcomes may be more related to a nursing home having more resources, or simply having better luck. It would be better to have incentives tied to things nursing homes can actually control. The danger with performance incentives is that the rich get richer and the poor get poorer and we compound inequities.

Q: How does the research you and others do translate to the operations of providers?

A: I wish I had a great answer –the implications for policy are more direct than they are for practice. Research by some underscores that the transmission of virus into facilities is often about staff who are asymptomatic – especially staff who work in more than one setting, or who live in high- transmission neighborhoods. This emphasizes the importance of getting staff vaccinated.

Q: Did your studies differentiate between nursing homes that are not-for-profit and for-profit?

A: Yes, we have looked at that, as have other researchers. Our team has not found a meaningful difference, but other studies have, however the difference is not large. It may be that some studies have not controlled for a variety of variables, such as the size of the facility. For-profits are often larger, and we know that correlates to more COVID-19.

Q: Did you find a correlation between private rooms and COVID-19 case counts?

A: We have not been able to study that as it is difficult to unearth that information, but it is a good question. There is some logic to that on the face of it.

Q: Is there an optimal size for a nursing home to have good outcomes?

A: That is not a question we have explored.