LTC Bullet:  Book Review:  “Take That Nursing Home and Shove It”

Friday, February 1, 2013


LTC Comment:  This new anti-nursing-home book disturbs and delivers on several levels.  Read our review after the ***news.***

*** LTC COMMISSION:  Today’s the deadline for appointments to the new Commission on Long-Term Care created by the American Taxpayer Relief Act of 2012.  According to the law:  “The Commission shall be composed of 15 members, to be appointed not later than 30 days after the date of enactment of this Act . . . .”  That would be today, Friday, February 1, 2013, but so far no news regarding appointments.  Well, I suppose if the U.S. Senate can ignore federal law by failing to pass a budget for four years, we shouldn’t be too surprised if the President, Senate and House leaders miss this deadline.  In the meantime, we’re waiting impatiently for news.  While government commissions usually just delay tough decisions, this one at least gives long-term care a level of public exposure and consideration it hasn’t received in decades.  Let’s make the most of it.  Stay tuned for our plans as, if and when this LTC Commission takes form.  ***



LTC Comment:  Gerontologist and elder law attorney Susan B. Geffen’s new book--Take That Nursing Home and Shove It:  How to Secure an Independent Future for Yourself and Your Loved Ones—delivers better on its sub-title than its crass lead.

Shove It begins as a diatribe against nursing home care.  It’s a sad indictment to read.  Examples of deficient care, too few caregivers, bad smells, greedy owners, lawsuits, etc. abound.  Author Geffen sees the problems with nursing home care up close and personal because she deals professionally with people and families in crisis who have few choices about where and how to get the care they need.  So I don’t doubt her passion or honesty on the topic.

And certainly, this book would help long-term care insurance salespeople sell their “stay-out-of-a-nursing-home” product, which Ms. Geffen’s book heartily endorses.  Because waking people up to the need to plan for LTC risk and cost is so important and really is the primary contribution of the book, I won’t hesitate to recommend it with the following qualifications. 

Take the book’s bitter criticism of nursing homes with a grain of salt and consider the following larger context.  Nursing homes are a critical part of the long-term care continuum.  They provide excellent sub-acute and rehabilitative care, for which they are well suited and amply compensated by Medicare and private insurance.  Most of the problems that Ms. Geffen describes derive from the use of nursing homes to provide long-term custodial care funded at parsimonious levels by a welfare program, Medicaid.

The nursing home industry has made and continues to make heroic efforts to improve care quality.  But the reality in this life is that you get what you pay for.  According to a recent study, Medicaid reimburses nursing homes $7 billion per year less than the cost of providing the care, more than $22 per bed day below “allowable costs.”  As one author put it as far back as a 1988 article in the Journal of Health Politics, Policy and Law:

One way to interpret the current market outcomes in the nursing home sector is to say that, despite protest to the contrary, state Medicaid programs are acting effectively to buy the services they wish to purchase for Medicaid patients--a limited amount of relatively low-cost care of uncertain quality.

For a few years, I served as an expert witness in nursing home liability lawsuits.  I saw disgusting conditions described at great length with stomach-turning detail in depositions against certain nursing homes.  But I also saw the exact same conditions described in identical boiler-plate language in case after case by the same law firms.  I became aware of highway billboards inviting people to contact law firms about problems with nursing homes, but only in states where liability laws made nursing homes easy to sue.  I came to wonder how much of the alleged poor care and abuse was real and how much contrived for monetary gain by tort lawyers and their clients.

I also concluded that care problems in nursing homes are not solely a problem of inadequate Medicaid reimbursement.  There is also the fact that too many--in fact most--people who receive expensive institutional long-term care rely on Medicaid.  Why is that?  Because contrary to conventional wisdom, Medicaid nursing home care is easy to get.  Income rarely stands in the way.  And virtually unlimited assets are exempt. 

Making the problem of over-reliance on Medicaid even worse is that Medicaid planning attorneys use a magic legal wand to qualify affluent seniors for Medicaid nursing home care.  Medicaid compliant annuities, special trusts, early transfers, promissory notes, reverse half-a-loaf strategies:  these and many other legal gimmicks divert Medicaid’s scarce resources to people who should pay their own way instead of to the neediest poor, the program’s proper clientele.

Unfortunately, I found little in “Shove It” to explain why our country’s inadequate LTC service delivery and financing system is the way it is.  Bitter criticism leaving the impression that evil people prey for profit on the helpless adds only ill will and mistrust to a very complicated story.  Far better is to focus on how to correct the deficiencies by eliminating their cause.

So take the many valuable parts of this book to heart.  Plan early and responsibly for long-term care risk and cost.  Buy long-term care insurance or use home equity as the author recommends.  But realize that access to quality care at the most appropriate level depends more than anything else on the ability to pay privately for care.  Private payers get red carpet treatment because they pay half again as much for their care as Medicaid does. 

Bottom line, don’t blame nursing homes or the good people in them who struggle to provide the best care possible despite huge obstacles.  Rather, put the blame where it belongs:  on poor government policy that trapped a generation of Americans in underfunded, welfare-financed institutions. 

Praise and empower the good people who take personal responsibility and prepare to pay for their own care if and when needed.  They and the people who struggle to wake them up to the risk and cost of long-term care, including the author of this bi-polar book, are the real heroes of LTC.