Nursing homes have accounted for an incredibly high number of covid-19 fatalities in the United States outbreak. As covered previously in Brief19, nursing homes accounted for 45 percent of the deaths in the U.S. as of late June, despite the fact that residents of these long term care facilities make up less than 1 percent of the nation's population.

A new article published in JAMA looks at potential drivers of disparities across nursing home facilities during the covid-19 pandemic. Interestingly, the researchers looked at the association between nursing home ratings by the Centers for Medicare & Medicaid Services (CMS) and covid-19 case load. These researchers looked at data from eight state health departments to determine the total number of covid-19 cases in nursing homes between January 1 to June 30, 2020. Nursing home ratings, quality measures, and nursing home staffing were extracted from CMS Nursing Home Compare, a database that tracks facilities performance. Over 4200 nursing homes were included in the study. 'High-performing' nursing homes had fewer cases of covid-19 compared to 'low-performing' nursing homes. Perhaps most interestingly, after statistical adjustment the only other factor associated with covid-19 caseloads appeared to be facilities with high ratings of performance by nursing staff; these facilities were less likely to have a high burden of covid-19 cases. No other quality measure domain was associated with an increase in the number of covid-19 cases in a particular nursing home. The authors conclude, "These findings suggest that poorly resourced nursing homes with nurse staffing shortages may be more susceptible to the spread of COVID-19." 

The major limitation of this study, however, is the absence of a denominator: how many residents were there per nursing home. Also missing was information about the presence or frequency of health or demographic characteristics that may predispose nursing home residents to developing symptomatic covid-19. Nevertheless, this paper provides evidence that appropriate staffing of nurses and other staff in nursing homes appears to be helpful in preventing increased covid-19 burdens in individual facilities. 

Last week Congressional lawmakers continued to negotiate but went into the weekend without an agreement on the details of a fourth phase of a stimulus relief package. With the Republican-controlled Senate supporting their HEALS Act (passed in July) and the Democratic-led House supporting the HEROES Act (passed in May), there appears to be substantial daylight (about $1-2 trillion depending on the cost estimate) between the two bodies' stances.

Democratic leaders state they have offered to reduce the price tag of their plan by $1 trillion, down from $3.4 trillion, but announced pushback from the White House. Meanwhile, President Trump tweeted that these same leaders wanted to meet with him to iron out a deal, a claim that Senator Schumer and Speaker Pelosi both deny.

What this means is that there is no solution in sight for the now-expired unemployment benefits, provider relief programs, loan forgiveness, and the myriad of other components that have encompassed past stimulus packages. The impact on the economy, including the effect on hospitals and other healthcare providing institutions, could be drastic as the fall approaches. Various.