Today, the Senate Special Committee on Aging convened a hearing to discuss what steps can be taken to better care for seniors during the COVID-19 crisis.
In her opening statement, Chairman Susan Collins (R-ME) described the impact of COVID-19 on older adults, noting that nearly a third of COVID-19 deaths nationwide are nursing home residents. Chairman Collins also referenced a letter she and Senator Kyrsten Sinema (D-AZ) sent to the Centers for Medicare and Medicaid Services (CMS) encouraging the agency to take steps to improve nursing home access to testing and personal protective equipment (PPE), as well as ensure the health status of nursing home residents is taken into consideration for the future distribution of treatment and vaccines. The Chairman noted that she hoped to gain insights from the hearing to inform additional Congressional action that helps to better protect seniors. Finally, Chairman Collins recounted some of the steps Congress has already taken, including the passage of four Coronavirus aid bills, and noted that she intends to introduce a bill to reimburse telehealth services provided by home health agencies.
In his opening statement, Ranking Member Bob Casey (D-PA) called for specific evidence that policies are being changed to give nursing home workers, residents, and family members more information. He stated that the policies and funding passed in the first four Coronavirus aid bills only “scratch the surface” of what is required and noted that Congress needs to do more. In particular, Ranking Member Casey suggested that the HEROES Act (legislative text; WHG client summary) would help achieve the goal of informing resource distribution by requiring nursing homes to collect data. Finally, Ranking Member Casey noted the importance of investing in home and community-based services (HCBS).
Dr. Mark Mulligan, Director, Division of Infectious Diseases and Immunology, Langone Vaccine Center; Director, Thomas S. Murphy Sr. Professor, Department of Medicine, New York University Grossman School of Medicine, explained that age inhibits immune response to COVID-19 and the immune response is further complicated by the presence of chronic conditions. He noted that the frail elderly residing in nursing homes and long-term care facilities are the ones most at risk. Dr. Mulligan also noted that these facilities have not had the medical countermeasures to appropriately care for residents. In addition, he further explained that medical countermeasures, such as vaccines, may need to be tailored specifically to seniors due to their physiological differences. See his full testimony here.
Dr. R. Tamara Konetzka, PhD, Professor of Health Services Research, Department of Public Health Sciences, University of Chicago, explained the challenges nursing home facilities face in responding to COVID-19, including being understaffed and competing with hospitals and others for PPE. Dr. Konetzka also discussed a recent study she conducted which looked at nursing home data from 12 different geographic areas. She found a relationship between race and COVID-19 deaths, but did not find a relationship between 5-star ratings and death. Dr. Konetzka also did not find a relationship between deaths and the for-profit or non-profit status of a nursing home. Finally, she noted there was a weak relationship with death and the number of residents on Medicaid.
Dr. Konetzka called on Congress to provide an influx of funding and technical assistance for staff, PPE, and regular and rapid testing of all nursing home residents and staff. She also recommended that the Medicaid benefit be expanded to ensure beneficiaries are able to receive home-based services. Finally, Dr. Konetzka noted it is critical that data be collected and that nursing homes are transparent about the rates of COVID-19 infection and death. See her full testimony here.
Dr. Steven Landers, President And CEO, Visiting Nurse Association Health Group, explained that the CARES Act and the Provider Relief Fund, as well as actions by CMS have helped allow home health agencies to continue to operate. In particular, he noted that the flexibilities granted to nurse practitioners (NPs) and physician assistants (PAs) have preserved access to care. More than anything, he explained that the COVID-19 pandemic has highlighted the need for a strong home care option. Dr. Landers explained that maintaining the PPE supply at 7 to 10 times the usual price, continues to be a challenge. He encouraged Congress to consider policies that allow home health agencies to have sufficient supply of PPE at a reasonable price. Dr. Landers also noted that telehealth has been a very helpful tool in caring for residents, however, home health is not reimbursed for those services. See his full testimony here.
- Importance of data. Chairman Collins kicked off the question and answer portion of the hearing by referring to a GAO report released on May 20 that found nearly half of the more than 13,000 nursing homes surveyed had infection control deficiencies in consecutive years, which the report deemed “an indicator of persistent problems.” Related to quality, Chairman Collins noted that stars ratings have not proven to be a reliable indicator, explaining that one of the worst outbreaks in Maine was in a facility with five stars. The Chairman suggested this indicates a need to think more about hospital discharge planning and asked Dr. Konetzka to discuss what could be done. Dr. Konetzka explained that “we’re learning a lot as we go” and good data is not yet available. Further, she noted that it is important to regularly test all residents, on a weekly or bi-weekly basis, and not wait until they are symptomatic.
Ranking Member Casey echoed the call for data on case counts and deaths in nursing homes to help direct and target resources, noting that he has introduced legislation that would provide $20 billion in emergency funding to facilitate data collection, among other things. The Ranking Member asked the panel “why is basic data so important? What are policies we can implement to secure this information?” Dr. Konetzka stated that data and transparency are critically important for informing where to direct resources. She explained that data is necessary to have for the future, so we can look back and understand what worked and what did not. Dr. Konetzka also explained that this data is important to consumers and their families so they can make informed decisions.
- Other vulnerable care settings. Senator Martha McSally (R-AZ) raised the importance of considering the impact of COVID-19 on seniors in other congregate living arrangements such as independent and assisted living settings – not just nursing homes and long-term care. She asked Dr. Konetzka what can be done to protect them. In response, Dr. Konetzka agreed that there’s a tendency to focus only on nursing homes but that assistant living conditions can be very similar. The difficulty, she said, is that assisted living centers are licensed by state.
Senator Elizabeth Warren (D-MA) also discussed the need to assess and monitor conditions in other types of facilities besides nursing homes. In response to this discussion, Dr. Mulligan confirmed that seniors in different settings are at equal risk. Noting that, “the virus doesn’t care where seniors are living.” Sen. Warren asked if assisted living centers are required to report data to CMS, and Dr. Konetzka confirmed that they are not, since they are not as dependent on federal funding. Sen. Warren noted that she has recently launched an investigated into how assisted living facilities are tracking COVID-19 and what measures they are taking to protect residents.
- Other vulnerable populations. Senator Doug Jones (D-GA) discussed the particular difficulties Alzheimer’s and other memory patients face during the COVID-19 pandemic, which witnesses agreed are even more challenging to address. Sen. Jones also asked witnesses to comment on the research indicating minorities and low-income people are disproportionately suffering from the virus. Dr. Konetzka noted that the factors which contribute to the COVID-19 disparities seen in nursing homes are similar to other disparities we see throughout health care and are related to systemic social issues.
- Tailored medical countermeasures for seniors. Senator Jacky Rosen (D-NV) asked if medical countermeasures may need to be tailored for seniors. Dr. Mulligan explained that yes, this is something that is done for the flu, and noted that measures may need to be tailored to seniors for COVID-19 as well. He explained that this is because stronger vaccines are sometimes necessary for older adults and noted that special studies will need to be conducted to determine what is needed for COVID-19. Dr. Mulligan further explained that treatments will also need to be tested for tolerance by seniors. Finally, Dr. Mulligan noted that antibodies may need to be created and infused for seniors if they are unable to make antibodies themselves.
Chairman Collins asked if seniors are currently enrolled in vaccine trials. Dr. Mulligan noted that Phase 1 trials are usually conducted in health young adults that later include a second group containing seniors and other “vulnerable” populations. Dr. Mulligan explained that he is also involved with an efficacy trial supported by the National Institutes of Health (NIH) that will include seniors.
- Increased support for nursing home, personal care, and other workers. Senator Richard Blumenthal (D-CT) expressed support for the HEROES Act to retain, reward, and recruit workers. He also asked if many nursing home workings are paid low wages, to which Dr. Konetzka explained that they were and added that many also do not have health care. Sen. Blumenthal inquired about the possibility of housing these workers elsewhere. Dr. Konetzka agreed that would be a good idea and noted that many hospital workers are being put up in hotels so they do not have to risk exposing their families. Finally, Sen. Blumenthal noted that he has introduced legislation which mandates nursing homes to provide PPE, safety training, an infection control preventionist, sufficient staff, testing, and virtual visits for residents and families.
Senator Kirsten Gillibrand (D-NY) also voiced concerned for workers in nursing homes. The Senator asked witnesses if nursing home workers had national paid leave prior to the start of the pandemic whether residents would have been better protected from the spread of the virus. Dr. Konetzka thought that paid leave could have helped in several ways, for example, by enabling greater flexibility, family members might have had the ability to care for their loved ones at home instead of institutionalizing them. Although she noted this solution would not address the staffing shortage.
Sen. Gillibrand explained that nursing homes are still struggling to get access to testing and PPE and suggested that an essential workers bill of rights is needed to protect them in the workplace. The Senator asked Dr. Landers if he believed outcomes for patients are better when workers are supported. Dr. Landers agreed that “to the extent we have a strong, well supported, and well-trained workers, we will have better outcomes.”
To address the shortage of workers, Sen. Gillibrand suggested developing a “health force” of one million trained workers over the next two months and asked the panel if that would help position the country for the future. Dr. Mulligan agreed that preparing and investing in public health infrastructure ahead of time is necessary. Dr. Landers also agreed that it is important to get more people into the field, but noted the long-term policy making is necessary to increase the nursing pipeline. Finally, Dr. Konetzka expressed her support for the idea in both the short and long-term, and explained that improvements to working conditions could go a long way in retaining workers.