Nursing Homes Are Struggling. Biden’s Proposed Reforms Will Make Things Worse.

Unfunded mandates to hire more workers won’t help improve quality of care when much of the industry is underwater or barely profitable.

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Nursing homes have struggled to provide quality care for decades, and attention on the problem has never been higher in the wake of more than 200,000 COVID-19 deaths among nursing home residents.  

But with the demise of the Build Back Better Act late last year, the hope of a sweeping reform agenda for long-term care (LTC) was thought to be over. 

Still, President Joe Biden continues to chase LTC reform. His newest proposal—while not as expansive as the BBB’s $150 billion for home care—seeks to improve the quality of care in nursing homes that house more than 1 million aged and disabled Americans.

In and of itself, Biden’s goal of improving nursing home care is commendable. Unfortunately, his plan treats only the symptom—poor nursing home quality—not the underlying disease. To provide better care to our frail and vulnerable, we must ask ourselves why nursing homes have poor quality outcomes in the first place.

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  1. Avatar photo
    Earl King

    Oh dear god. A subject with which I have intimate knowledge. As a Paramedic I get the be recipient of a lapse in care. If I had a dollar for every time I have been called to an acute situation that would not have happened if care had been administered earlier, I be a very wealthy man.

    I get called for stupidity at Nursing facilities but I also get called when someone is on the road to dying. I have been told that a patient was perfectly normal at breakfast and 3 hours laters he is unconscious, struggling to breath and septic. Amazing. Of course when I find out the Pt. had untreated pneumonia, I am incredulous......there is no sudden onset of pneumonia. There is no sudden onset of Congestive Heart Failure, where I find the Pt. literally drowning needing immediate intubation. Both of these incidents take time to develop. Time enough for someone to have observed Pt. distress.

    If had a dollar for these words, “I just came on”. The unconscious Pt. with a systolic BP of 58 and purple mottling on his legs leaving me to quickly grab to 1000 millimeter bags of fluid to get in him only to find out I inevitably put him in to congestive heart failure. Again, it doesn’t happen in a few hours, it all take time.

    I go in to the best facilities and the worst State run (Medicaid) facilities, both have problems. From the heart transplant Pt. who was in congestive heart failure...(water in the lungs from poor cardiac performance) who was laying flat. When I asked the RN why the Pt. was laying flat he told me the bed was broken. The string of F bombs I let loose out of exasperation at the RN wasn’t fair to him but he was quickly behind the Pt. sitting him up. Pt. to RN ration at a nursing home is likely 20 to 1. The rest is filled in with patient care associates and LVN’s (licensed vocational nurse). One Doctor may makes rounds in the AM, and quickly review Pt. charts.

    Nursing homes have less staff on the weekends. No PT's or OT’s, perhaps no respiratory therapists ....Therefore we refer to Fridays in my job as "patient dump Friday". Any patient that may need monitoring or nursing for some kind of problem is sent to the hospital for evaluation. Since hospitals won’t immediately turn them around and may keep them overnight they likely won’t discharge on a Sunday.

    The fix is easy, we all know what it is. Keep people at home as long as possible. If they have family it is easier if the Pt. has family, reserving the Nursing home for someone who needs constant nursing. My mother is at home. She ran thru here “at home” care 1200 visits and now the only way to get insurance money is if she went in to a Nursing home. She doesn’t need nursing care, just daily living help like food, and bathing etc. Money is the answer, lots more, teams of people that visit patients every day and take vitals and listen to lung sounds, cardiac monitor. Some people need live in help.....These job are hard and the pay is crap. Keeping people healthy is key, but also and I say this not to be mean but as a statement of fact.....our medicine is keeping the chronically ill alive longer with no quality of life. I’m not sure what to do about it.

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  2. Avatar photo
    Tmcke

    Unfunded mandate is a catch phrase. And there is no willingness to provide more government funds. So what to do? The suggestion for more home care may be a good one, but it seems even here, we have agencies that harvest large pools of dollars and disburse much smaller pools of wages.

    If the writer wants to talk about health care as a whole, then why not talk about our now almost fully corporatized healthcare system.

    So for now, the mandates are a well meaning and useful beginning.

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  3. Avatar photo
    Will Bates

    $285 a day isn’t enough?!

    For that, you could hire a 1:1 ratio of aides to elders.

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      Mudskipper

      No, you can't. Not 24 hour care at a competitive wage. Why would anyone want to work a night shift changing diapers and wiping butts at $12 an hour?

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  4. Token Liberal

    I have been involved in many Investigations of nursing homes. While some of the statements in this article have some accuracy, I have observed enough greedy, horrible owners of for profit nursing homes to see this article as a defense of horrible greedy people who will deprive people of care to line their own pockets.

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  5. Avatar photo
    Mudskipper

    "To improve nursing home quality and financial solvency, the U.S. must embrace reform that reduces Medicaid’s role while helping individuals and families better prepare for the eventual need for LTC."

    And exactly how is that to be done? It is an easy thing to say, but how can that be accomplished?

    I don't think private LTC insurance as it now exists is the answer. (And I say this as someone with a LTC care policy.) Premiums are higher than most families can afford and the payouts are not likely to completely cover the cost of LTC. Moreover, it seems to me that the industry is facing a crisis as medical science keeps extending the life of seriously mentally and physically frail people and as it gives us ever better glimpses of what our future might be. I read recently that there might be a test of coming out soon that fairly accurately predicts your chance for developing Alzheimer's years before you develop any overt symptoms. This kind of foreknowledge will steer the people who might need LTC the most into buying a policy while others might decide to take their chances without one. Or, if the LTC insurance companies are privy to the results of your test, it might cause the insurance premiums to become completely unaffordable to those who are most likely to need LTC.

    LTC is a major crisis facing us and I suspect we will fail to address the crisis, unfortunately. Our main hope is medical science delivering some cures or at least some mitigations for dementia.

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    1. Gregg Girvan

      Hi Mudskipper, thanks for reading. You're right, it is easy to say but hard to accomplish. The primary aim of the article was to point out that at the present time, what Biden is proposing would do more harm than good. That said, I am leading a project at FREOPP where we will be outlining a broad reform agenda for LTC. It requires a multi-faceted approach. The financing aspect obviously needs a serious overhaul, but changes are needed with staffing issues as well as the care settings; e.g., nursing homes often are architecturally based on a communal design that makes the spread of infectious diseases like COVID worse. Also, the Program of All-Inclusive Care for the Elderly (PACE) is a promising model that combines home care with an adult day care setting that has successfully diverted many from nursing homes, with high satisfaction from family caregivers as well as cost savings over nursing homes. So yes, there are ways to address the problems, but we won't get there overnight.

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        Mudskipper

        My pessimism is based on the fact that both the left and right have ideological constraints that keep them from being pragmatists willing to use whatever tool--whether that be the government or private industry--that would work best in any given situation. And both are likely to let the perfect be the enemy of the good, at least when it comes to criticizing each other's solutions.

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  6. Jayne R.

    I don't suppose that raising the reimbursement rates would be an option? Staff costs money, medicines and supplies cost money. If Biden wants to mandate something, how about reimbursing these places their costs at least?

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    1. Gregg Girvan

      Jayne, this is certainly one way to go and one that most LTC advocates support. One issue to keep in mind is Medicaid is a joint federal-state program, so any federally mandated reimbursement increases will impact state budgets, which have to be balanced each year and where Medicaid often compete fiercely with K-12 education for state dollars. The share of reimbursement states must pay is also at the normal (read: higher) rate for LTC, as opposed to spending for the ACA Medicaid expansion group (which the feds cover at 90%). Congress could certainly increase the federal share of the cost for LTC, but given the already large cost of LTC and projected growth, plus current inflation rates in the economy, and it appears such a thing would be a tough sell.

      Thanks for reading and commenting.

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    CynthiaW

    "Still, Medicaid is biased toward nursing home care since states limit access to HCBS through waitlists to keep overall program costs low."

    This is confusing. If home and community based services are "less expensive per enrollee," as the sentence preceding my quote said, then why does limiting their use "keep overall program costs low"?

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    1. Gregg Girvan

      Cynthia, thanks for reading. See JR's comment in this thread. This is known as the "woodworking effect," since people that have forgone paid LTC will come out of the woodwork for home or community-based care rather than nursing homes because they prefer it. States maintain waiting lists because if the demand is big enough the total cost will exceed the fewer, but costlier per beneficiary, residents in nursing homes.

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        CynthiaW

        Thank you. That answers my question!

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      JR

      The short answer: "Induced demand."

      A longer answer: Some people might not seek care in a nursing home (which saves money for the Medicaid budget) but would seek care in a home-based setting (which draws on the Medicaid budget).

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        Pat @ Tavi Hall

        Two thoughts, not sure they work together. First you keep overall cost of home service low by not using it at all or making it hard to get. Next once you start to need these services, your rational decision making is on the decline.

        I weighted the choice of home care not just by it's much larger $ cost but by my own perception of the need to do a lot of micro managing to keep it on place. I mean what happens if the person who helps an older person with their meds doesn't show. That didn't happen at nursing homes.

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      Pat @ Tavi Hall

      I found it a myth that home based services are cheaper. You have to compare apples to apples. 24/7 home care will run you double what a nursing home costs in my area.

      The biggest reform that would help is evaluate people in terms of need, for some a stipend could be paid to, yes, gasp, family members. It wouldn't have helped me at the end. But it might have helped my dad to have been able to pay helpers and sitters. The professional social worker I worked with in their placement was shocked to learn he died first. I can't prove it, but I think, feel, that she wore him out.

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        CynthiaW

        Thanks, that's interesting. (Doesn't explain the apparent inconsistency in the article, though.)

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          Mudskipper

          It is confusing. However, I think it might come down to the type of senior being served. Some seniors can stay in their homes if they get some occasional help. For example, a meal delivery service or someone who comes by for a few hours each week to help them bathe, run errands, and do chores around the house like changing light bulbs. Also, a social worker who stops by periodically to help them get adaptive equipment they might need or extra services they might need would be very helpful. Without this kind of help, relatives might well move the senior into a nursing home paid for by medicare which would be more expensive.

          Then there are the seniors who need daily care or even 24x7 care. Private caregivers are very expensive and by the time you get up to needing more than 8 hours a day care, it is probably cheaper to put someone in a nursing home.

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    Aylene Wright

    This is a quite eye opening explainer about an industry that often gets demonized as run by a bunch of greedy or at least stingy Scrooges, heartlessly raking in profits on the backs of suffering seniors.

    That's pretty much the framing of anti-Cuomo Democrats for his decisions to actually force nursing homes to take COVID positive patients, that somehow the facilities must have bribed or at least pressured him into that decision because they financially benefitted from it, or something. But if their profit margins were already so low, seems the added costs of COVID-19 isolation measures might negate any profit from keeping the patients there. 🤷‍♀️

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      Tmcke

      Just curious if you are from the NY area. I have lived near NYC for almost all my life. I know cops, firemen, civil servants etc. Almost everyone saw Cuomo as a bully. No one really liked him. Not working the issue of nursing homes which never had the resources to handle COVID.

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  9. Avatar photo
    Pat @ Tavi Hall

    Reading this, comparing it to my own recent experience with my parents. I'll highlight that near as I can tell, no one who needs to go to a nursing home gets to make that decision. Either your family will make it for you or the institutions you get into by a fall or other health emergency will put you into one. Now, don't take this to mean there are lots of mentally competent folk living against their will in nursing homes, in the plus year of dealing with them, I saw only one person who MAY have been competent.

    In our case, we did get Medicare payment for my mom's rehab treatment. What this article doesn't make clear, is that it's very limited. In my experience in six such admittances over a decade, only one of those extended beyond the 21 days you get for free. That one that went beyond was a second admittance for a second broken hip a mere week after discharge for the first broken hip. That high Medicare rate also includes rehab services, almost always Physical therapy, and occupational therapy, often speech therapy (which covers things like swallowing as well as actual speech). These services happen everyday.

    But after the second event, my mom could not return to the assisted facility I had found that would take both my parents in an apartment setting. They had long term health care insurance which paid her costs. I had calculated that with their income and their house sale, they would not spend down to Medicaid eligibility until after they were 100. Interestingly all the nursing homes I looked at billed pretty much the same as that Medicaid rate, between $220 and $240 a day.

    Honestly I thought both my parents got better care at the more run down nursing home type facility than they did at the glorious assisted facility they briefly stayed in. That assisted facility was most definitely a part of a big corporate chain and while things looked good actual health care seemed a bit slipshod. But, the best care was definitely at the nursing home that was locally owned and run by the owners as their primary business.

    I wrote about my experience, mostly with idea of helping those like me who got thrown into things. A lot of things you hear don't really match reality. As an FYI, my blog needs to be read in reverse order so start on the part I link and keep clicking on the "newer post" link. I'm not really much of a writer, so if it doesn't appeal try looking up Teepa Snow on YouTube. She's funny and has lots of insight and tips. https://momfelldown.blogspot.com/2020/06/the-fog-of-war.html

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    1. Gregg Girvan

      Pat, thank you for reading, for all the comments you posted, and for sharing your experience. I figured I would respond to all of your comments on this part of the thread.

      You are absolutely right in that Medicare is very limited in what it will cover and in what circumstances. I will say that while most admittances will have to pay some out of pocket past 20 days, the cost paid by Medicare is still significant. And for those on Medicaid, it covers the balance. So for many, the cost sharing is much less expensive than paying out of pocket.

      Everyone's experience is different, but I will say the rates of satisfaction in other settings for both patients and caregivers is higher than nursing homes on average, assisted living included. Again, personal experiences will differ, but on the whole, nursing homes tend to struggle more, and that's before the COVID pandemic hit. I am thrilled your experience was different, and absolutely, the fact that the owners ran the home locally probably had a big impact in the quality of care. I wish they all ran that way.

      On LTC insurance, it really can be a great product for certain people. The good news is the LTC insurance market has stabilized considerably in the last couple years compared to the wild premium swings we were used to seeing. And I think there are some things we can do to make the product better and should encourage as many as possible to buy it. But I have become more convinced over time that it isn't the primary solution. The premiums are prohibitively expensive for many, but even for some who could otherwise afford it, they don't buy it primarily for one of two reasons. First, they either think Medicare or some other program will cover them in retirement, or second, they still view the cost as high because Medicaid is there as a payer of last resort; in other words, the existence of Medicaid places an implicit tax on the price of LTC insurance that makes many people think it isn't worth the cost. Granted, you may have to spend down to get Medicaid, but Medicaid also excludes some big assets from the asset counting rules to qualify for Medicaid, including home equity of at least $636,000 and a primary automobile of any value. So LTC insurance will always have a role, but in order for it to play a larger one, we would have to significantly downsize Medicaid's role...not an easy thing.

      As for home services: I agree in the sense that if you require home care 24/7, it is definitely more expensive than a nursing home. But I actually don't think that's an apples-to-apples comparison either, because in many cases, people in nursing homes, especially on Medicaid, could receive the care they need without 24/7 assistance but are in a nursing home because Medicaid won't cover anything else in their area. We know this in part because PACE (Program for All-Inclusive Care for the Elderly) will not admit anyone into the program unless they qualify for a nursing home level of care, and yet those folks receive a combination of care at home and at an adult day care facility, all for a lower cost than a nursing home. The real question is, for a particular person with a particular set of limitations, which care setting would meet their needs for the lowest cost? And in most cases, the care setting would be something other than a nursing home. Again, individual circumstances will vary. For many family caregivers they have an easier time with nursing homes and a lot of good facilities stay on top of a person's care. But many do not. The scenario you painted where a care worker misses giving a person his or her meds? It happens in nursing homes way more than you think.

      On stipends for family caregivers, I absolutely agree 100%. They are rock stars and deserve a heck of a lot more support. My wife cared for her mother in our home until she died in Feb. 2021, so we've definitely been there.

      Again, thanks for reading and for sharing. We can all learn from each other and bring more awareness to these important issues.

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      dmklever

      I worked most of my career in LTC insurance. It's always good to read that someone got benefits out of their policy.

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        Pat @ Tavi Hall

        I told the grandchildren who were her heirs, that although she was the "spendthrift" of their marriage, she had suggested the insurance. That one decision almost doubled the size of the estate.

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