Long-Term Care Expert David Grabowski: Home-Based Care Versus Nursing Homes Is a ‘False Dichotomy’

Long-term care providers have always had to stay on top of ever-changing shifts in trends, policies and regulations. The COVID-19 emergency has only made this task even more important.

In today’s fast-paced environment, Harvard Medical School professor David Grabowski has turned into a major voice. Since last year, Grabowski has applied his expertise to a range of senior care topics, from home-based care spending to SNF-at-home programs.

A professor in the department of health care policy, Grabowski’s work is concentrated on the economics of aging, with a focus on post-acute care and long-term care. Throughout his career, Grabowski has also participated on a number of Centers for Medicare & Medicaid Services (CMS) technical expert panels while serving as principal investigator on several research projects funded by the National Institute on Aging.

To learn more about emerging policies in the post-acute and long-term care arenas, Home Health Care News caught up with Grabowski — a Medicare Payment Advisory Commission (MedPAC) member as well — for our latest episode of “Disrupt.” Highlights from the conversation are below, edited for length and clarity.

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HHCN: Policymakers and health care leaders have been working to shift more care into the home. How does home care spending in the U.S. compare to other countries?

Grabowski: This is a really great place to start the conversation. We’re ahead of some countries, but unfortunately behind others. We’re sort of in that big middle part of the distribution. There are times when you look at the U.S. relative to other countries, and we’re an outlier. Yet when it comes to home care spending, we’re a bit of an inlier, maybe even toward the lower end of the curve, especially compared to some of our European friends.

We’re definitely behind on investment in the home and in the community.

Even drilling down within the U.S., there are certain markets — even states — that have seen quite a bit of investment around in-home services, whereas other other parts of the country kind of lag behind. I think the story here is very mixed, whether you compare us to other countries around the globe or just looking across the U.S.

Some have argued that there should be more investment around home- and community-based services and less in nursing homes. You’ve been critical of that view. Why?

I think we’ve set up this false dichotomy, in many ways. There are those who think that every dollar that’s spent on home- and community-based care has to come out of nursing homes.

First and foremost, I should be very clear: I’m for individuals getting long-term care services in the home or the community. That’s what people want. That’s what I would like to see them get. However, my research, along with my general experience of living many decades here in the U.S., has found that it’s very hard to abolish or eliminate nursing homes entirely. There’s always going to be some group of individuals who need nursing home services.

Let’s get as many individuals as we can in home- and community-based services, but for those individuals who need to enter a nursing home, let’s make those nursing homes as strong as possible.

I think that means reimagining nursing homes. Nursing homes today are far too institutional. The staffing is far too hierarchical. They don’t really meet the needs of the residents. It’s not about resident quality of life and quality of care. Very few facilities around the country are resident-directed. If you talk to residents, they feel very little sense of purpose or control over their lives. We need to flip that.

I really have called for both investment in home- and community-based services and in the reimagining nursing homes. Once again, I don’t view those as opposing goals. I view them as complementary. We need to set up a spectrum or a system of services that meets the needs of individuals who receive care in the community but also those who might need to receive care in an institutional setting.

Let’s make that setting less institutional and more home-like. That means potentially smaller environments, where staff members are well-compensated and valued. And where the residents have control over their environment.

We saw some home health providers last year set up their own SNF-at-home services, or at least talk about doing so. UnityPoint at Home and LHC Group are two examples. What’s your high-level take on the SNF-at-home concept?

This is a really fascinating model. In the spirit of full disclosure, I was involved in a pilot project with some colleagues here at Harvard — at one of our affiliated hospitals, Brigham — to pilot one of these programs as well. It is a very small study, and it’s still out under peer review, but we actually found relatively positive results around the model.

But once again, a very small intervention that was being tried here.

The reason it was so small is Medicare isn’t yet paying for this. When we did the trial, we had to go forward with this model with just internal funding. The concept has a lot of promise. You’re basically providing services where the individual wants them — in their home. But you’re not simply giving them home health. That’s not meant as a criticism of home health, but I really believe there’s a group of post-acute care patients that could thrive in the home, but need more than the usual package of home health services. And that’s really the SNF-at-home model.

Like any new model, however, we have to really wonder where the demand is going to come from. Is this really, you know, that we’re going to pull individuals out of SNF settings and deliver services for them at home, allowing them to thrive in the community and potentially save payers money? Or is it going to be largely individuals who would have gone home anyway and might have done fine under the home health benefit? Are we pulling some of those individuals into this new benefit? Does that lead to higher spending?

I’m a big proponent of encouraging high-value post-acute care services and deterring those lower-value services. When it comes to the SNF-at-home model, though, we need to really make certain it’s targeting those higher-value services that not only are offering great quality and great outcomes for the beneficiary, but also helping to offset some spending for the program.

We need to avoid those instances where the program isn’t offering much additional quality or outcomes, but maybe leading to a lot more spending. Again, I’m very excited about the potential of the model, but a little bit wary of who actually ends up receiving services under it. I think targeting there is going to end up being very important.

Just to be clear, I’m speaking for me, not for MedPAC. But obviously, I’m somebody who actually has some level of insight into the process at MedPAC

I think it comes back to that word I used earlier: value. We know that the Medicare margins for home health have been quite big over the last [several years]. Other indicators that MedPAC uses to evaluate the adequacy of payments seem to suggest, you know, that this is a really robust sector. There’s lots of for-profit entry. There aren’t many Medicare beneficiaries who can’t get services under the home health benefit. This is a healthy industry — and that was true pre-pandemic.

What about the pandemic’s negative impact on the industry, especially early on?

When we talk about rate increases, it’s really important to separate what happens with the natural kind of updates that occur every year versus what happened during the pandemic.

Post-acute care providers — whether it’s SNFs or home health agencies, or even other parts of the health care system like hospitals, physician offices, you name it — if they need resources in the form of relief funds, let’s get them those relief funds. But that doesn’t mean we should build that into their annual [rate] update.

I think we need to treat those as two separate issues. One, how do we make certain that all of our providers had the right tools in place to deal with the pandemic? I think we did that as a health care system. Then, we need to kind of step back and say, “Are there areas where we think there may be some low-value care?” I think that’s what the MedPAC recommendation is about. It’s not that the home health benefit is bad or anything like that. It’s that we’re overpaying for those kinds of services right now. There needs to be some adjustment there, separate from anything that’s going on with the pandemic.

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