Alex Spanko for Skilled Nursing News wrote a great article about the financial structure that is the shaky foundation of long term care in America. “At the base, Medicaid supports long-term care residents who can no longer live on their own without around-the-clock care. Medicare dollars pay for higher-acuity care that seniors require after hospital stays — and prop up insufficient Medicaid reimbursements that can’t financially sustain a nursing home on their own.”
To protect themselves from liability and ambitious plaintiffs’ attorneys, operators covered up the windows to their offices with complex webs of intertwined ownership and management companies that even veteran journalists have struggled to unravel.
While such legal maneuvering is common and generally accepted in any industry with a significant real estate component, the nature of the clients that nursing homes serve — and the occasional horrific stories of serious lapses in care — made the media and the public deeply suspicious of what exactly was going on behind the curtain.
Then the hurricane-force winds of the COVID-19 crisis blew the whole structure down.
No one paying attention to the news, and watching the rapidly climbing coronavirus death toll at our nation’s nursing homes and other long-term care facilities, can be blamed for being angry. My own blood pressure spikes when I go through my inbox each morning, scrolling past story after story about shortages of protective equipment and temporary morgues in refrigerated trucks.
The federal government has taken some positive steps — restricting visits and focusing on infection-control inspections early in the process chief among them. While the industry itself has been out in front of CMS in many aspects, especially around calls for greater transparency about the number of reported cases, these steps reflect some understanding of how serious the situation would get, even before “social distancing” became a nationwide edict.
But the administration’s inability to coordinate the distribution of personal protective equipment (PPE) and COVID-19 testing kits represents a profound failure. In the United States, nurses should never have to use garbage bags and ponchos to protect themselves and their patients. In the United States, everyone should be able to receive testing during a pandemic, but CMS and states should have pushed nursing homes to the front of the line at the very first signs of danger.
Clearly, we are in unprecedented times, and well-meaning officials are going to make mistakes as they work to fight an unseen enemy. It’s just one example, but it reveals the deep tensions that exist between state and federal oversight of nursing homes, both from a regulatory and payment standpoint.
Operators must rely on the perfect combination of federal Medicare dollars and state-level Medicaid funding to survive. The two care models that those funds support couldn’t be more different, but persistent Medicaid shortfalls have made providing both short- and long-term care a necessity.
Without the Medicare money, a building simply can’t support itself or its residents on Medicaid alone — but as COVID-19 has revealed, bringing post-acute residents into a setting with even more vulnerable long-term care patients can be a recipe for disaster.
Once the danger passes, lawmakers at all levels need to deeply question the ways that federal and state rules around nursing homes overlap and diverge. Big-picture thinkers have long predicted the development of a site-neutral model, but it’s time to seriously consider a single federal payer source for all types of long-term and post-acute care. A split Medicare-Medicaid model, born largely by accident and sustained by inertia, falls apart in a crisis.
When the coronavirus crisis abates — and operators and caregivers are no longer pleading for access to PPE and testing — my personal hope is that providers, lawmakers, and investors take seriously the opportunity to reflect on the failures baked into the system.
Maybe it’s finally time to prioritize across-the-board increases in wages for the people who have spent this crisis putting themselves and their families at risk, even if it’s at the expense at profit margins — temporary hazard pay and one-time stipends aren’t enough to fairly compensate these essential workers.
Maybe it’s finally time to embrace wholesale changes to payment models, instead of perceiving each tweak and update as an attack on the heart of the industry.
Maybe it’s finally time to tear down the wall of suspicion and derision that leaders on both sides have built up between the public and nursing home operators.