Dealing With The Nursing Home Crisis

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Dealing With The Nursing Home Crisis

BY KATHLEEN B. DEOUL

 

As the American population ages, more and more families are making the painful

decision to place a mother, father, or other loved one in a nursing home. For

most families, this choice is a reluctant one, only made because of some

pressing health issues, and only after obtaining assurances from sympathetic and

attentive nursing home officials that their relative will receive the best of

care.

 

What they don't realize is that is the last time the nursing home bureaucrats

will be so accommodating.

 

The sad truth is that rather than assuring their loved ones receive appropriate

medical care, the decision to place them in a nursing home may actually put the

patient at risk of serious physical harm or even death.

 

Consider a few startling examples:

 

In a Salt Lake City, Utah nursing home, a nurse fails to label medications

and as a result they are given to the wrong patients.

In a Hobe Sound, Florida nursing home, a patient suffering from a broken

tibia was not given appropriate pain medication even though the nurse's notes

indicated the patient was up all night crying due to pain from the break.

A Midwest City, Oklahoma patient was given powerful antipsychotic drugs even

though no assessment had been performed to determine if they were necessary!

At a Warren, Arkansas nursing home, attendants failed to perform required

glucose checks on a diabetic patient 37 times, and even administered insulin to

the patient 18 times without performing such checks first to see if it was

needed and what the proper dose should be.

 

Nursing home operators would argue that these are isolated incidents, and while

regrettable are not typical. Roughly 3.5 million people will live in nursing

homes over the course of a year - which means that 15% of all families will have

a loved one in a home for some period of time. Nursing home operators contend

that in such a large patient population, some unfortunate incidents are

unavoidable.

 

They would have a point, if the incidents were in fact isolated. But the truth

is that they are not. Dr. Edward C. " Terry " Watters, a nationally recognized

expert on nursing home quality cites an appalling statistic in his book " Danger

Zone. " According to Dr. Watters, in any given year, patients are either harmed,

or placed at serious risk of harm in fully 25% of the nation's nursing homes. If

more than one year is considered, the figure doubles.

 

But that's not the worst.

 

According to the Government Accounting Office, 40% of the homes where the most

serious incidents occur are repeat offenders. The GAO cited what it calls the

" yoyo " effect in which a home is cited for a deficiency and gets a slap on the

wrist. In response, the home takes nominal corrective action to assuage state

and federal regulators, but as soon as the heat is off, reverts to its old

practices.

 

Nursing home operators claim that the blame does not lie with them. Instead,

they point a finger at the federal government asserting that under new rules for

reimbursements from Medicare and Medicaid, their costs are no longer covered and

as a result patient care suffers.

 

Under the old rules, the government paid " reasonable " costs for any medical

services provided. This, of course created an incentive for nursing homes to

provide as many services as possible, and costs began spiraling out of control.

Since fully two-thirds of all nursing home care is paid for by Medicare and

Medicaid, Congress became alarmed at the effect rising outlays for nursing home

care was having on the cost of Medicare and Medicaid. As a result, in the 1997

Balanced Budget Act, the payment system was changed to one based on fixed rates

for Medicare and Medicaid-covered nursing home stays. But nursing home operators

claim the fixed rates don't cover their costs and have created a financial

crisis.

 

In particular, they say that Medicaid reimbursements only cover about 93% of the

cost of patient care, making it necessary for the homes to offset the loss with

higher charges for patients covered by Medicare and private insurers.

 

But is this really true?

 

Not according to an examination of nursing home financial statements performed

by U.S. News and World Report. Their exhaustive investigation found no

correlation between the profitability of nursing homes and the number of

Medicaid patients they served.

 

So if Medicaid is not the culprit, what is?

 

Nursing home operators also claim that hospitals, seeking to reduce costs now

send them patients who are much sicker than they once were, requiring more

sophisticated medical capabilities than were needed in the past.

 

This sounds reasonable on the surface. After all, the extra equipment and

trained personnel that would be required to treat seriously ill patients is

expensive, and certainly could raise costs.

 

But if this were true, a measure of patient health medical professionals call

" acuity " would be rising at the nation's nursing homes. This allegation, too,

was examined by U.S. News, and found wanting.

 

According to the magazine's exhaustive examination of patient evaluations at the

nation's nursing homes, in the three years between 1998 and 2000 (the most

recent data that was available) the acuity level of patients in American nursing

homes did not change. For example:

 

The percentage of patients who were bedridden remained constant at 5%.

The percentage of patients with potentially life-threatening bedsores remained

constant at just under 10%.

The number of patients with infections remained constant at 17%.

The number of patients who were incontinent remained constant at 60%.

 

In other words, for the three years reviewed by the magazine, no change in the

nature of nursing home patients was evident.

 

Now, if nursing home patients are indeed sicker than they were in the past, it

would be logical to assume their personnel would have to spend more time with

their charges. Yet according to a study by the University of California, the

time nurses and nurses aids at homes which specialized in accommodating

Medicare-reimbursed beds spend with patients has actually decreased.

 

The result in this decline in time spent with patients, according to Dr.

Watters, means that " Your loved one will be left alone 21 hours a day. "

 

The lack of attention to patient care is underscored by the Government

Accounting Office findings which discovered that when nursing homes did raise

spending, the funds were typically used for increased administrative services or

financing, not additional nursing care.

 

But if the nursing home industry is in financial trouble, where does their

estimated $92 billion in annual revenues ($58 billion from taxpayer-funded

Medicare and Medicaid reimbursements) go?

 

As it turns out, to a number of questionable financial practices that suggest

their profits may actually be far higher than they admit.

 

One of the most blatant bits of financial legerdemain is the practice of

" self-dealing. " Accountants refer to this as " related-party transactions. "

 

In plain English, this is basically moving money from your left pocket to your

right.

 

It is interesting to note that it was exactly this practice that was behind the

Enron scandal.

 

According to U.S News, their researchers found that fully 70% of all nursing

homes engaged in related-party transactions.

 

Indeed, employing this sort of scam allows nursing home operators to claim

poverty at the same time they are lining their pockets with federal dollars.

 

One example illustrates the point.

 

A nursing home operator in Indiana claimed his facility was losing money - and

on the surface his balance sheet indicated it was.

 

But that was only on the surface.

 

As it turned out, the operator had a second company that provided things such as

equipment and real estate to the home. The nursing home paid exactly half of its

revenues to the operator's other company for such services. On further

examination it was discovered that other nursing homes in the small chain he

operated sent him an average of 30% of their revenues, totaling some $4.4

million a year.

 

This example is not unique.

 

In New York, a couple who owned a nursing home paid their affiliated management

and real-estate firm $2.8 million in rent and $4.9 million in management fees in

a single year. The nursing home also provided the couple with a $4 million

interest-free loan.

 

Another New York nursing home operator paid herself some $1.8 million over two

years in management and consulting fees and paid another $500,000 to a relative

for consulting services.

 

While the nursing homes cited in these examples were among the roughly

two-thirds of all nursing homes that are operated for-profit, the abuses are

also evident among so-called non-profit nursing homes.

 

In a sense, when non-profit homes are involved in such self-dealing the abuse is

even more egregious, because their clients assume that the lack of a profit

incentive is likely to translate into better patient care. But sometimes, the

non-profit label is little more than a false flag to lure potential clients into

a false sense of security.

 

For example one Baltimore Maryland non-profit was paying millions of dollars in

management and consulting fees to other for-profit firms run by their

executives. Ironically, the home's non-profit status made it exempt from

corporate income taxes and eligible for tax-exempt financing, giving the

operators an even bigger piggy bank to raid.

 

How long it will take Congress and federal regulators to resolve our nation's

nursing home care dilemma is an open question. Millions of American families,

however, cannot wait for the government to act - they have a loved one in need

of care NOW. So what can they do to ensure their loved one gets the care they

deserve?

 

One person who has struggled with the question and come up with an answer is Dr.

Terry Watters a prominent Maryland ophthalmologist.

 

Seven years ago, Dr. Watters got a first-hand glimpse into the cavalier attitude

towards patient care all too common in for-profit nursing homes that steeled his

resolved to do something about it.

 

It began when one of his patients was admitted to a Maryland nursing home. While

making a routine visit to check up on his patient, Dr. Watters noticed that the

individual's condition - which was sight-threatening - had grown worse. On

further investigation he discovered that the treatments he had ordered had not

been given. He was stunned by the reaction of the home's staff after he noted

the deficiency in the patient's chart. Rather than offering some explanation for

the failure to administer the treatments, a staff member instead asked him not

to make the notation because it could " cause trouble " for the home with state

agencies.

 

On several subsequent visits, Dr. Watters found that the prescribed treatments

had not been administered and complained to the staff. Again, the only concern

his complaints elicited was the danger that his notations in the patient's chart

might cause problems with state agencies. The final straw came when on a

subsequent visit to his patient, who again had not been treated he was told that

his notes had been removed from the record because they would constitute a " red

flag " for state regulatory officials.

 

Outraged, Dr. Watters went to the state agency responsible for regulating

nursing homes and filed a formal complaint.

 

Nothing happened.

 

Now he was really mad. He was convinced that it was not just his patient who was

at risk, but that every patient in the nursing home could be in danger. So Dr.

Watters went to his state senator and asked him to intervene.

 

An emergency review of the nursing home's paperwork found that they were indeed

falsifying records and had even covered up the death of a patient.

 

So, heads rolled - right? Wrong!

 

The nursing home got an administrative slap on the wrist - but no fine - and Dr.

Watters got a letter from the home revoking his privileges.

 

Not one to take things lying down, Dr. Watters began collecting data on Maryland

nursing homes and then analyzing what he discovered. The picture that emerged

was worse than he could have imagined.

 

He discovered a system where the patient was nothing more than a pawn caught in

a vice between state officials whose only concern was to minimize costs and

corporate executives who were determined to squeeze the last penny out of every

resident. Neither side showed the slightest concern for the welfare of the

patients.

 

It was at this very time that his battle with the nursing home establishment

became very personal.

 

A few years after he began his fight to improve the quality of nursing home

care, his mother became a resident of a home in Annapolis, MD. Unlike most

relatives who place a loved one in such a facility, Dr. Watters had no illusions

about the need to monitor the care his mother received. Moreover, as a

physician, he knew how to read a medical chart and determine whether or not the

home was doing everything for his mother that it should.

 

Armed with this knowledge, he felt assured that he could look out for his

mother's interests. He soon found out how wrong he was.

 

When he asked to see his mother's records, officials at the home initially

stonewalled, then delayed, and often provided incomplete copies. It was then,

that Dr. Watters realized he had to learn the rules - how to get access to his

mother's records. But he realized something else as well - that if he, as a

physician who could read a medical chart and understand it was having such a

hard time getting answers, the situation was virtually hopeless for the average

individual.

 

But Terry Watters is not someone who can ignore a problem. He has to try to

solve it.

 

In thinking about his own experience, Dr. Watters came to recognize two key

problems people face when making the difficult decision to place a loved one in

a nursing home.

 

The first problem is how to find out just how good the care offered at the home

really is. Although state and federal agencies keep voluminous files of data on

these facilities, the information is not readily available to the general

public. From his own experience in researching the quality of nursing home care,

Dr. Watters understood that it would be difficult to understand for someone who

lacks medical training even if they did gain access. But he also realized that

he had compiled exactly the information a laymen would need and had performed

much of the requisite analysis to make it understandable.

 

Powered with this realization, Dr. Watters and an associate, Dennis Steele

designed a website, Member of the Family.net (memberofthefamily.net) where

individuals could obtain the information they needed.

 

The site is packed with important information. It contains a listing, organized

by state, of some 16,000 nursing homes across the nation. Each of the homes is

rated on the basis of actual government reports using a simple four level scale

indicating the facility's performance. The levels range from " no violations " to

" actual harm and/or immediate jeopardy. " The scale also indicates where there

have been multiple violations at a particular nursing home. The worst offenders

are featured in a " National Watch List " comprised of nursing homes that have had

recent violations or substantiated complaints for " actual harm. " There is also a

" National Honor Roll " of nursing homes with outstanding records.

 

For families trying to find a nursing home, this information is invaluable.

 

But Dr. Watters also recognized that identifying a nursing home with a good

track record only solves half the problem. Even when a nursing home has a

relatively clean record, there is no guarantee that your loved one will get the

kind of care they deserve. The sad truth is that state regulators are so lax

that what passes as acceptable in their eyes would appall most uninterested

observers.

 

The only answer for this problem, Dr. Watters knew, was for the patient's

guardians to take the bull by the horns and oversee their care. Of course, for

someone without medical training, the notion of taking on a nursing home staff

is a daunting prospect - especially since the cards are stacked in their favor.

To address this problem, Dr. Watters drew on his own experience and training.

 

When Dr. Watters tried to intervene in his own mother's care, he quickly learned

that the key to success was in knowing what was in the medical records. But he

had an advantage over most people - as a trained physician he knew how to read

medical records and what they should contain. To a layman, these records might

as well be in Chinese - unless they had a way to decipher the hidden meaning -

and that's just what Dr. Watters put together.

 

Along with his associate Dennis Steele, he wrote " Danger Zone " a step by step

manual on how to obtain your loved one's medical records, what information they

should contain and how to understand the information that is written on their

pages. He describes the six basic elements of a medical chart, and provides

actual copies of charts that have been annotated to explain what information is

on them, and what it means.

 

In addition to telling you how to read medical records, it also explains how to

spot instances where the records have been falsified. " Danger Zone " also shows

how to ask questions about medical treatment plans so that you know your loved

one is getting the proper medical care, and how to deal with nursing home

administrators and staff to make sure your wishes are followed. Perhaps most

important it shows how you can use the laws and regulations enacted to protect

nursing home patients to force care providers to provide proper care for your

loved one and provides samples of letters you can use as a guide when writing to

nursing home administrators, doctors and government regulators.

 

It is, in short, a comprehensive, easy to use handbook no one contemplating

putting a loved one in a nursing home should be without. If you want a copy, you

can order it through the memberofthefamily.net website.

 

It is a sad commentary that books like the one Dr. Terry Watters has written are

needed, but the fact is that they are. The nursing home industry spends tens of

millions of dollars on lobbyists each year to ensure that no one examines their

practices too closely. States, faced with an aging population and the prospect

of a huge increase in the number of nursing home patients are far more concerned

with containing costs than in the quality of care. As the Baby Boom generation

continues to age, and their need for nursing home care increases, a public

outcry may eventually bring about needed reforms, but for the present, it is up

to individual families to ensure their loved one's rights are protected. Dr.

Watters' website and book are invaluable tools for attaining that goal.

 

 

 

 

 

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