Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. His Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, appears here at Time Goes By twice each month.
If you have a friend or a loved one in a nursing home, with the holidays coming on, this would be a good time to check closely on conditions in the home and the quality of his or her care. For this economic downturn and Medicaid reductions in some states may be affecting the level of care, especially in for-profit homes that may cut corners to save money.
I say “may’ because some nursing homes are warning of staff layoffs and even closures, but there is little real evidence that residents are being affected. But the Centers for Medicare and Medicaid Services (CMS) recently updated its lists of so-called Special Focus Facilities (SFFs), which include scores of homes that have a history of serious problems such as the conditions and staffing of the institution and the level of care.
In August, the Government Accountability Office surveyed the ten-year-old SFF program and estimated that 580 of the 16,000 nursing homes in the country “could be considered the most poorly performing.” In addition, CMS lists dozens of other homes on the SFF lists – at least one in every state - have not shown substantial improvement in the past year or so.
CMS, which uses state agencies to monitor the homes, separates the SFFs into five categories:
- homes recently added to the list that need improvement
- those that have improved
- those that have not improved
- those that have improved enough to be removed from the list
- those that are so poor they have lost Medicare and Medicaid participation
You may check out the list of homes considered SFFs for your state here [pdf].
Also, last December CMS began a five star rating system for the nation’s nursing homes. This compares the level and quality of care for facilities by area.
The concern about the recession’s effect on nursing home care was touched off, in part, by a widely circulated wire story last month in which an official of the American Health Care Association saw the possibility of layoffs in nursing homes. The story said the nursing home industry was in crisis, partly because “Congress is debating slashing billions more in Medicare funding a part of health care reform.”
But there are a number of pending proposals to strengthen long term care. And while Medicaid funds have been cut in many states and Medicare is cutting some direct payments to nursing homes over the next decade, the GAO and the official Medicare Payment Advisory Commission (MedPac) say the nursing homes have enjoyed billions in overpayments, especially for skilled nursing facilities, where patients who are supposed to get one-on-one therapy are among three or more getting treated at the same time.
With aides paid too little (less than $10 an hour) to attend to too many residents, MedPac found that nursing homes profits exceeded 10 percent for seven consecutive years. And the profit margin for nursing homes in 2007 was 14.5 percent.
The GAO noted, incidentally, that “the most poorly performing homes tended to be chain affiliated and for-profit and have more beds and residents.”
Richard Mollot, executive director of the New York-based Long Term Care Community Coalition, a watchdog group, told me that while it would be wise to keep a special eye out on the care given to loved ones:
“Providers are always crying that they don’t have enough money...basically there have been cutbacks to the raises facilities were expecting.”
And he noted that inflation has been minimal. He cautioned against buying into the predictions that cutbacks are necessary and cited the wire story‘s report on layoffs at three homes in Brooklyn in the Metropolitan Jewish Health System. In 2004, The New York Times, discussing the poorly paid aides, reported that the head of the system, Eli Feldman, earned over $1 million in salary.
Whatever the finances of the nursing home industry, the Obama administration, elected a year ago this week, has encouraged the Democratic Congress to propose a host of bills to fix problems large and small with long term care. One bill, for example, would make it easier for families to file complaints on behalf of patients and open the books on who actually owns, runs and profits from the homes. Another bill would strengthen programs to prevent patient abuse.
The most important proposal is part of the Senate Health Committee’s bill for health care reform. Introduced by the late Senator Edward M. Kennedy, it’s called the Community Living Assistance Service and Support Act, or CLASS.
Among other things, it would enroll workers over 18 to gradually build a long term care fund financed by a payroll tax. They could opt out, but the fund would in five years finance the long term care of enrolled workers who need help. The initial benefit, about $100 a day, for home or nursing home care, is small, but it would relieve some pressure on Medicaid, and supporters see this as a start to solve what AARP has called “the greatest unmet health need,” the lack of public long term nursing care.
The bill is also included in the House version of health care reform and is expected to survive after it is combined with the more conservative one from the Senate Finance Committee. But not surprisingly, it’s opposed by the American Association of Long Term Care Insurance which fears it will put private insurers out of business. That would not be a bad idea, but we can talk about the worth of long term care insurance at another time.
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