LTC Bullet: Paean to Providers in Pain

Tuesday, June 10, 2003


LTC Comment: Rodney Dangerfield has nothing on nursing homes when it comes to getting respect. More after the ***news.***

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The challenges facing nursing homes are legion: low government reimbursements, fewer private payers, bankruptcies, a dearth of capital, staff shortages, quality questions, tort liability, and public image, to name a few. Who's at fault and who cares?

Who is at fault?

Many critics blame the "nursing home industry." But who is the industry? Mostly, underpaid and under-appreciated Nurses' Aides who provide loving care under difficult circumstances mostly to financially and physically needy elders. And Directors of Nursing who struggle to ensure care coverage and quality in spite of high staff turnover caused by the caregivers' high stress and low salaries. Plus hard-pressed Nursing Home Administrators, who must meet strict government-imposed quality mandates despite heavy and growing dependency on low and declining Medicaid reimbursement rates. Finally, Nursing Home Executives and Trade Associations probably take the most flak from critics, even as they fight to keep the industry profitable, or at least financially viable, while their principal payer--government--keeps changing the rules and reducing the price it's willing to pay.

Who's really to blame? Not who! Rather, what is to blame? In our experience, the vast majority of individuals involved in long-term care service delivery--from unpaid family caregivers to employees at all levels of the for-profit and non-profit nursing home, assisted living, and home health industries--are hard-working, deeply dedicated, intensely caring people doing their best under nearly impossible conditions. With some exceptions of course--every industry has its bad apples--the people of long-term care are not at fault, but rather the system in which they labor is the culprit. We say: change the system, free the people, save long-term care.

What's wrong with the system and how can we fix it? No need to go into detail about that today as we've already answered the question many times from many perspectives in this space. In a nutshell, nearly 40 years of easy access to government-financed long-term care has anesthetized the public to the risk of long-term care, discouraged personal responsibility for and private financing of long-term care, and finally overwhelmed Medicaid and Medicare, which together are no longer able to pay long-term care providers adequately. For details on how this happened and a proposal for what to do about it, see "LTC Choice: A Simple, Cost-Free Solution to the Long-Term Care Financing Puzzle" at . In the meantime, consider this question.

Who Cares?

Who really does care the most? Is it the "senior advocates" who demand a bigger role for government and pooh-pooh the potential of privately financed long-term care? Is it the seething critics of long-term care providers who demand more rules, regulations and quality mandates while ignoring the critical question of how to pay for them? How about the Medicaid planners, who manipulate the welfare program to qualify their affluent clients and then sue nursing homes when Medicaid pays too little to support quality care? Think about it. Across the board, the most supremely confident and self-righteous critics of long-term care providers are the very same people who profit from, sustain and seek to expand the utterly insupportable status quo.

Compare them to the caregiving saints featured in last October's PBS special "And Thou Shalt Honor . . ." (reviewed in "LTC Bullet: And Thou Shalt Honor," published September 23, 2002, at .) Or the over-burdened, understaffed providers of long-term care described above. Or how about those other AMGs--altruistic, masochistic, geniuses--who struggle to sell long-term care insurance, a product intended to fulfill a need about which nearly everyone is in denial because government has convinced them, albeit wrongly, that it will pay. Why do we vilify the people who fight, against staggering odds, to make a bad system work in spite of itself while we exonerate others who excoriate providers and advocate policies that will make a hopeless system even worse?

What a mess! To us, the solution is clear. Target government financing of long-term care to the genuinely needy and encourage everyone else to pay privately through home equity conversion in the short term and private long-term care insurance in the long run. But until that solution--which will immediately pump much-needed financial oxygen to LTC providers--is implemented or another is found, let's try to cut long-term care providers some slack. Recognize that in long-term care, as in anything else, what you pay for is what you get. Providers have been asked to make a silk purse (of care) out of a sow's ear (of inadequate public financing). When long-term care providers fall short, let's temper the criticism with appreciation for the heroic efforts they make to succeed in spite of all the obstacles. And let's direct more analysis and criticism toward the Pollyannas who benefit from and seek to expand the deficient status quo.

Following are excerpts from and a link to a recent New York Times article that describes some of the challenges nursing homes face and how some workers and managers are fighting back. This article makes our point: blame the system, not the providers; fix the system, empower the providers. Carl Young, President of the New York Association of Homes and Services for the Aging, who is quoted in the article, serves on the Center for Long-Term Care Financing's Board of Directors.

Richard Pérez-Peña, "Overwhelmed and Understaffed, Nursing Home Workers Vent Anger," New York Times, June 8, 2003,

"Nursing home workers in New York feel overwhelmed and ill-treated, and fear for the care of residents, largely because staffing is inadequate, a new study says.

"The study, by the Nursing Home Community Coalition of New York State, which acts as an advocate for nursing home residents, is to be released this week.

"It bolsters the findings of federal studies that have shown nursing homes to be short-staffed, a national problem for decades. Figures compiled this year by the federal Centers for Medicare and Medicaid Services, a branch of the Department of Health and Human Services, show that almost one in four nursing homes in New York State have staff-to-patient ratios below the level that a federal report called potentially dangerous to residents' health.

"Operators say they agree that many nursing homes are understaffed, but they argue that the homes cannot afford to pay for more people. The fault, they say, lies with government, because programs like Medicaid pay most nursing home costs, and the rates those programs pay are not high enough to sustain better care. . . .

"'We are burning out,' one registered nurse was quoted as saying. 'We do too many things.'A licensed practical nurse told the authors, 'We are at unsafe staffing levels.' Another said, 'I am often the only nurse on the floor.'

"'I have no time to speak to the residents,' a nurse's aide was quoted as saying. 'One resident called me in one night. She grabbed my arm and asked me to hold her. I gently removed her hand and explained that I had 16 residents to care for and could not stay. She died the next day. All she wanted was someone to be with her. I felt terrible.' . . .

"Carl Young, the president of the New York Association of Homes and Services for the Aging, which includes more than 300 nursing homes, acknowledged the need for more workers. 'We agree that everyone would benefit from having more staff,' Mr. Young said, 'but there aren't the people out there to hire, and there isn't the money to pay for them. There are simply not enough people coming into the field, whether nurses or L.P.N.'s or nurses' aides, or even doctors, because very few do geriatric medicine,' he said. 'It's very demanding work that's not for everybody, and for some of the lower-skilled positions, the wages are low and turnover is high. We often hear about providers pirating staff from one another.'

"The bulk of care in the homes is provided by nurses' aides, who generally earn $12 an hour or more in New York City, where many of them are unionized, and as little as $8 or $9 an hour upstate.

"Mr. Young said that 56 percent of the state's homes lost money in 2001, and that incomplete reports show they did worse in 2002.

"The Centers for Medicare and Medicaid Services, formerly called the Health Care Financing Administration, commissioned a study of nursing home staffing under President Clinton and completed it in 2001. It concluded that if the hours worked at a home by nurses and nurses' aides fell below an average of three hours per day per patient, the residents' health was put at risk, and it recommended at least 4.1 hours. . . .

"Assemblyman Gottfried, a Manhattan Democrat, said the bill he planned to introduce in the next few days would set a three-hour-per-day nursing care minimum, and would prohibit homes that fall short from admitting any new residents.

"But he acknowledged that bringing homes up to his proposed standards would cost $1 billion to $2 billion per year, mostly in the form of higher Medicaid payments by the state. . . ."