For a nursing home in Kansas, accepting a new resident discharged from a hospital while needing hospice care can be risky if the resident relies on Medicaid — and fewer and fewer nursing homes are willing to take on those patients.
It's easy to understand why when hearing about the experience of Asbury Park of Newton. This fall, Asbury accepted a such a patient, provided care — and never got paid.
"During October a resident died while their application was pending with the State of Kansas. We had to write off $10,000 of their care we already delivered," said Tom Williams, CEO of Asbury Park.
A long-running backlog of Medicaid applications has hit the bottom lines of Kansas nursing homes in recent years. Beneficiaries of Kansas’ privatized Medicaid program, KanCare, have waited months to see their applications approved while their nursing homes provide care for which they aren’t paid.
Now, health care officials said, those nursing homes may be hesitant to take patients who are going to die soon — afraid they’ll never get paid for the care they provide.
"The issue is the state’s lack of organization to process the volume of claims delaying payment from 90 to 180 days," Williams said. "Taking individuals whose applications are pending is extremely risky for any organization not knowing if and when they will get paid .... We have wages and bills to pay and cannot accept the risk of admitting individuals whose applications are pending for Medicaid assistance."
The Kansan first reported on waiting list issues and how they were affecting nursing homes in 2016.
Morgan Bell, a licensed master social worker at Stormont Vail Hospital of Topeka, works in palliative care and ensures patients have a safe place to go to the hospital. She raised the issue last week to legislators on a KanCare oversight committee.
Bell said none of the Topeka-area nursing homes readily take patients who are waiting on KanCare and are likely to die soon.
“That’s been the biggest issue is they don’t want to take on that financial risk because they just haven’t been getting paid,” Bell said.
Nursing homes have reported struggling to make payroll and pay food vendors because of the financial struggles they have faced, including cash flow problems caused by the backlog. The providers recently raised concern about severe fines they’ve received from the federal Centers for Medicare and Medicaid. State surveyors inspect the facilities and send reports to the federal government, which signs off on them and levies fines.
Bell said Stormont Vail has been able to provide funds to get some patients the care they need. One woman moved to the area to be close to family, but wasn’t yet approved for KanCare. Bell said Stormont Vail put up some funds in a contract with Midland Care.
“It’s not something that we can do for every single patient, and it’s not fixing the problem,” Bell said. “It’s just kind of filling a tiny gap for the moment.”
The woman died before she was approved for KanCare, Bell said.
Cindy Luxem, president and CEO of the Kansas Health Care Association, said she had heard the trend from her members, more than 200 long-term care providers. She said the issue was state-wide.
Luxem said nursing homes can get compensated for care they provided to a since-deceased resident, but it’s a different process than the normal reimbursement procedure.
“But that is a long drawn out process, so it’s a major problem right now,” Luxem said.
Bell said she would like to see patients who have a limited life expectancy get “presumptive eligibility.” That would mean certain providers could immediately enroll them in KanCare rather than waiting for an application approval. Angela de Rocha, a spokeswoman for the Kansas Department for Aging and Disability Services, said in an email only pregnant women, certain disabled people and foster children got presumptive eligibility. Bringing presumptive eligibility to patients with short life expectancies would require a budget increase, a decision for the Legislature, de Rocha said.
Right now, de Rocha said, social workers can mark KanCare applications as an “urgent medical need” to move them ahead in line.
De Rocha said continuing to reduce the backlog would help build trust between KanCare and nursing homes, “giving nursing facilities confidence to accept those individuals while they wait for eligibility to be determined.”
Last week, more than 2,000 applications were awaiting approval more than 45 days after they were submitted.
Luxem said her nursing homes weren’t immune to the backlog struggles.
“I can’t even begin to tell you the uncompensated care that our providers have given over the last few years,” Luxem said.
Rachel Monger serves as vice president of governmental affairs for LeadingAge Kansas. Monger said her members had not reported being hesitant to take dying patients, but she thought it made sense. When the backlog emerged as a serious problem, homes were hesitant to take any residents who were waiting on KanCare, Monger said.
“When you compound that with this very real possibility that the resident may die before approval and you don’t get paid at all ever, that makes complete sense — why that would be happening,” Monger said.
Monger said it was hard when homes had to turn potential residents away, but staying in business had become a matter of “survival.”
“They are in the business of caring for people,” Monger said, “but they have been pushed up against the wall to the point that you have to choose between doing what you want to do, which you feel is the right thing, and just surviving and keeping your doors open and being able to care for all of the rest of the residents in your building.”
Bell said moving into hospice was difficult enough for patients and their families without struggling to find a nursing home that could take them.
“It’s probably the worst time that most of these people have gone through, and that’s really the last thing they should have to worry about,” Bell said. “They should be able to spend time with their family member, or their family member should not have to worry about putting their family members through financial burden when they die.”