Commentary: Nursing Home Care: Code Blue

By Joseph Weber

A few weeks before last Christmas, Helen Tomlin was ready to go home. After five months in a nursing home, where she had been linked to a ventilator that pumped air into her emphysema-wracked lungs, the 76-year-old greatgrandmother was keen to see her family. "She was feeling better. She was smiling," recalls her husband, Harold. But on Dec. 7, he got a devastating call from the Bellbrook (Ohio) home. A maintenance man had mistakenly hooked a nitrogen tank into an oxygen system that supplied Mrs. Tomlin and other residents. She and three others died, and six were hurt. The Tomlin family is suing for $10 million, and criminal indictments have been lodged against the home's owner, Integrated Health Services Inc. (IHSVQ ), and the gas tank supplier. Both have pleaded not guilty.

A tragic aberration? Sure, but for 1.7 million Americans in nursing homes, it is an extreme example of mistakes that are becoming all too common. Already, substandard care has become the shocking norm at too many of the nation's 17,000 nursing homes (table). Bedsores and malnutrition are rife, and mentally incapacitated residents occasionally flee to wander on nearby roads. Industry executives say finding qualified workers is a dire problem. "There is not enough money in the overall system," says Michael R. Walker, CEO of Genesis Health Ventures Inc. (GHVIE ), a national home operator.

At one level, the issue is simple economics. Unwilling or unable to provide for their waning days, too few people set aside enough money or buy insurance to cover nursing care. So much of the bill has fallen to the government. Of some $96 billion a year going to such homes, about $58 billion comes from federal programs, mostly Medicaid. Even so, the industry's finances are so parlous that six of the country's biggest for-profit chains--including Integrated Health Services and Genesis--slipped into bankruptcy reorganization in 2000. In Nevada and New Mexico, nearly half of homes operate under court supervision, as do more than 20% of those in 12 other states.

But there's a more fundamental problem. Haphazard national policy has turned the industry into a tortured, quasi-governmental affair begging for reform. Medicaid is designed to help the poor. But many have taken advantage of the rules by switching their parents' assets out of their name. The families then get to keep their inheritance, and the nursing home tab gets dumped onto taxpayers. "We artificially impoverish them, that gets them nursing home care, and we get early inheritances, and attorneys line their pockets," complains Stephen A. Moses, president of the Center for Long-Term Care Financing, a Bellevue (Wash.) nonprofit.

TROUBLE AHEAD. Because we haven't officially acknowledged that Medicaid has become a middle-class entitlement program, Congress never sets aside enough dough to keep the system fully funded. The result: Nursing homes are fast going backward toward the chronic maltreatment of the 1960s. The Bush Administration has proposed a few tax incentives that would help a little. But the problem will only get worse if we don't tackle it head-on: As the elderly population swells, it will double federal nursing home spending by 2010 and continue to soar thereafter.

Washington will have to come to grips with the dilemma. One extreme would be to formalize nursing home funding, perhaps through a Social Security-like system that collects worker and employer contributions in every paycheck. The opposite tack would be to insist that middle-class families foot the bill themselves (although devising rules to prevent asset-switching has proved to be difficult). A middle position could be to use tax incentives to persuade the middle class to purchase long-term care insurance, an idea Congress has toyed with in recent years.

Whatever approach we adopt, a national dialogue should take place as part of any discussion about 10-year tax cuts. Otherwise, Washington may be forced in a few years to ask taxpayers to foot the bill, in effect giving back all the cash lawmakers now plan to dole out. As it stands, "we have no coherent long-term care strategy in our country," says Charles H. Roadman II, head of the American Health Care Assn., a trade group.

CRAZY QUILT. Repeated seesawing on policy and funding by Washington and the states has added to the confusion. For example, when congressional budget-balancers wielded their knives in 1997, they slashed Medicare funding and changed the rules under which nursing homes operated. This rendered uneconomical many ancillary businesses that industry players had created in response to earlier government incentives, such as respiratory therapy and rehabilitation. Washington again changed the rules in 1999 to help the industry, only to later cancel its "refinements" after government officials objected. Finally, President Clinton offered a salve to the ailing industry last year by chipping in some $1.6 billion over five years as part of a Medicare relief bill--an amount industry leaders say is scarcely enough.

The problem is exacerbated by the wildly different amounts of government money homes get around the country. Washington pays 57% of the cost of Medicaid, with the states picking up the rest. But states administer the program and set many of the rules. The result is a crazy quilt of reimbursement levels, ranging from $122 a day in North Dakota to more than $340 a day in Florida. Care levels vary, too. Texas pays about $296 a day, but government investigators have found that at least 25% of homes there operate with rule violations that hurt residents or put them at risk of death or serious injury.

President Bush has a few proposals that at least begin to address the nursing home problem. To jump-start long-term care insurance, he wants to broaden a Clinton-era tax deduction. He also would let families take a personal exemption for the elderly they care for at home. Moreover, the federal government plans next year to give federal employees the chance to buy group long-term care coverage. Companies should follow suit. If such coverage were to become as common as 401(k) programs, it would help steady the system's finances.

Still, government can't shirk its role as funder of last resort and policeman. Truly needy seniors--who might not have well-off descendants to turn to--cannot be turned out on the street. Regulators also must make sure that staffing ratios and care are appropriate. Mandatory staffing ratios that had been considered in the 1990s ought to get a fresh look.

As Congress ponders tax cuts, nursing home care should be part of the debate. "The American public is more than ready for a dialogue," argues former Senator David Durenberger, chairman of an advocacy group called Citizens for Long Term Care. We owe our parents and ourselves no less.

Corrections and Clarifications "Nursing home care: Code blue" (Social Issues, May 7), which cited varying state reimbursement levels for nursing home care, should have specified that the figures used were Medicare reimbursements.

Weber covers health-care issues from Chicago.

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