<img src = "https://media.npr.org/assets/img/2018/11/30/gettyimages-629416761_sq-0468fbefd953d2cd668addb4ce3f5587f78d8c68-s100-c15.jpg" data-original = "https: // media .npr.org / assets / img / 2018/11/30 / ink-629416761_sq-0468fbefd953d2cd668addb4ce3f5587f78d8c68-s100.jpg "class =" img lazyOnLoad "alt =" Medicare to cut payments to nursing homes whose patients end up in hospital  The reduction in total fines also occurred when the Centers for Medicare and Medicaid Services inflicted 28 percent more frequent financial penalties than they did with Obama.This increase in the frequency of citations with financial consequences arose due to of
a policy initiated towards the end of Obama's mandate that required regulators to punish a facility whenever a resident was harmed, instead of leaving it at their discretion.
While that policy increased the number of fines more small, the largest fines have become less common. The total amount raised under Trump has fallen by 10 percent compared to the total in Obama's final year – from $ 127 million under Obama to $ 114 million under Trump. (We compared the penalties during 2016, last year in Obama's office, with sanctions under Trump from April 2017 to March 2018, the most recent month for which federal officials say the data is reliably completed.)
CMS claims to have reviewed more rules governing fines in both administrations to make its punishments more correct, more consistent and better adapted for improve care in nursing homes. "We are continuing to analyze the impact of these combined events to determine if other actions are needed," CMS said in a written statement.
The shift to financial penalties minors is substantially consistent with the Trump administration other sectoral policies in the health care sector. For example, the administration has expanded the role of short-term health insurance policies that do not cover all types of services, gave states greater room for maneuver to change their Medicaid programs and urged Congress to allow the doctors to open their own hospitals.  Beth Martino, spokeswoman for the American Health Care Association, a commercial group for nursing homes, says the federal government "has returned to a method of applying fines in a way that encourages problem resolution" rather than penalizing " the facilities that are trying to do the right thing. "
Sanctions guidelines were reinforced in 2014 when the Obama administration instructed officials to favor daily fines. By 2016, this approach was applied in two thirds of cases. Those fines had an average of $ 61,000.
When Trump took power, the rest home industry complained that the fines were broken "out of control" and had become disproportionate to the shortcomings. "We have seen a dramatic increase [fines] to be released retrospectively and used as punishment," wrote Mark Parkinson, president and CEO of the American Health Care Association, in March 2017.
CMS agreed that daily fines sometimes resulted in punishments determined by the random timing of an inspection rather than by the gravity of the infringement. If the inspectors visited a house in April, for example, and discovered that an improper practice had begun in February, the accumulated daily fines would be double those that would have been if the inspectors had come in March.
But moving to a preference for fine penalties means much smaller penalties, since the fines are limited to $ 21,393, regardless of whether they are applied by instance or by day. Nursing homes that pay without contesting the fine receive a 35 percent discount, which means that they currently pay a maximum of $ 13,905.
Such peaks also apply to structures that have committed the most serious level of violations, which are known as immediate risks because the practices of the nursing home put residents at imminent risk of harm. For example, a Mississippi nursing home was fined $ 13,627 after finishing the drugs because it relied on a pharmacy 373 miles away in Atlanta. CMS also reduced $ 54,600 in daily fines to a single fine of $ 20,965 for a New Mexico home where workers had not properly disinfected equipment to prevent the spread of infectious diseases.
On average, the fines for Trump's case were less than $ 9,000,
"These are multimillion-dollar companies – $ 9,000 is nothing," says Toby Edelman, a senior lawyer at the Center for Medicare Advocacy, an & Non-profit organization in Washington.
Large daily fines, with an average of $ 68,080, are still issued when a house has not corrected a violation after being sued. But even in these cases, CMS officials are allowed to make exceptions and issue a single fine if the house has no history of substantial violations.
The agency warned that comparing average fines is misleading because the overall number of inspections resulting in increased fines increased under Trump, from 3.5 percent in 2016 to 4.7 percent. The circumstances that justify the fines that were not issued before tend to impose penalties from the lower part.
However, Kaiser Health News found that financial penalties for immediate risks were issued in fewer cases under Trump. And when they were issued, the fines were on average 18 percent less than those of 2016.
The frequency of the immediate danger fines can decrease even more. In June, CMS told inspectors that they were no longer required to fine structures, unless immediate violations led to "serious injury, damage, impairment or death". The regulatory authorities have yet to intervene, but it could be the home office's order to organize training from an external group or to impose specific changes to the way the house operates.
Barbara Gay, vice president of public policy communications at LeadingAge – an association of non-profit organizations that provide services for the elderly, including nursing homes – says nursing homes "do not believe they have received a truce "under Trump.
But consumer advocates say the sanctions have returned to levels too low to be effective.
"The fines must be large enough to change the behavior of the structures," says Robyn Grant, director of public policy and defense at the National Consumer Voice for long-term quality, a non-profit organization with based in Washington, DC "When it is not the case and the fine is irrelevant, the cure generally does not improve".
Kaiser Health News is an independent and independent news service supported by the Kaiser Family Foundation. KHN is not affiliated with Kaiser Permanente. You can follow Jordan Rau on Twitter: @jordanrau .