[LTPC-disc] Fw: LTC Bullet: Paean to Providers in Pain

[Doug Burg]

----- Original Message ----- 
From: "Center for Long-Term Care Financing" <ltcbullets@centerltc.org>
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Sent: Tuesday, June 10, 2003 5:58 PM
Subject: LTC Bullet: Paean to Providers in Pain


LTC Bullet:  Paean to Providers in Pain

Tuesday, June 10, 2003

Seattle--

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LTC BULLET:  PAEAN TO PROVIDERS IN PAIN

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
http://www.centerltc.com/pubs/CLTCFReport.pdf .  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
http://www.centerltc.com/bullets/archives2002/386.htm .)  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,
http://www.nytimes.com/2003/06/08/nyregion/08NURS.html?pagewanted=print&position=

"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. . . ."

A formatted version of today's LTC Bullet is available at
http://www.centerltc.org/bullets/current/445.htm .



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