Three cheers for benign neglect
I've been researching and writing this column for nearly 15 years, but all good things eventually come to an end. This is my final column as Washington Editor for Nursing Homes/Long Term Care Management. While you read these words, I am fulfilling a lifelong dream on faculty at the University of Guam, America's westernmost land-grant college.
Ironically, although Guam is the second most populous of America's overseas territories, it has only one nursing home program. St. Dominic's Senior Care is operated by the Catholic Archdiocese of Guam primarily as a residence for the elderly whose families have left the island. In effect, it is closer to the traditional “old age home” than to the 21st century concept of a skilled nursing facility (SNF). One reason for this condition may be that the local government has not provided sufficient funding to allow the island's sole civilian hospital to maintain its accreditation standards; if an elderly resident of St. Dominic's requires critical care, he or she must face a two-hour flight to the nearest JCAHO-accredited medical center in the Philippines.
The case of Guam is a chilling lesson in what might have occurred in the United States if long-term care policy trends during the 1990s had been allowed to continue. At the end of the 1990s as many as one-third of the SNFs in the United States faced potential bankruptcy. The states that were responsible for providing the funds for hundreds of thousands of elderly long-term care patients also were facing financial crises and threatening to cut reimbursements to the bone without regard to the impact on quality or accreditation.
The past seven years have witnessed a quiet resurgence of the nursing home as an institution. Part of this may be due to expectations resulting from demography: There is a growing population of older Americans born during the post-World War II “baby boom” who will have both the need and resources to enter residential long-term care. Additionally, the rise of assisted living has provided an attractive transition from full independence to the increased care that is associated with the chronic conditions of aging.
These factors alone, however, cannot explain how SNFs collectively recovered from the brink of disaster. The oldest members of the postwar baby-boom generation are still in their early 60s and most are at least 10 to 20 years away from permanent residence either in assisted living or a SNF.
An alternative explanation for the changing fortunes of the long-term care industry is improvements at the policy level. Some credit must be given to changes at the state government level. Several states worked closely with representatives of the long-term care field to reduce the costs of care and improve reimbursements. In Iowa, for example, residential and home-based long-term care were brought together into negotiations with the state care funding agency to generate a rational reimbursement plan that recognized that thousands of older Iowans were facing care needs after their children and grandchildren had left the state. New England states reduced the costs of the medications purchased by long-term care providers by including the facilities in bulk-buying arrangements. And other states found ways to creatively “game” the Medicaid system in ways that effectively increased federal reimbursements.
The biggest difference over the past several years, however, undoubtedly resulted from changes at the national level. The absence of senior presidential advisors from the recent White House Conference on Aging illustrates that the administration of President George W. Bush has not identified long-term care reform as an urgent priority requiring White House attention. However, President Bush made several appointments early during his term of office that benefited the long-term care field. Two of these were Secretary of Health and Human Services Tommy G. Thompson, a former governor of Wisconsin, and Tom Scully, administrator of the Centers for Medicare & Medicaid Services. “Tom and Tommy” worked in tandem on a variety of issues including evidence-based practices, case-mix adjustments, refinements of the Resource Utilization Groups, and incentives for quality improvement. These seemingly “wonkish” initiatives were not the type of headline-grabbing stories that the White House press office likes to promote, but they resulted in solid improvements in both the operation and financial stability of long-term care. Other leadership on long-term care appeared in the federal Office of Personnel Management, which made significant strides in marketing the idea of private-sector long-term care insurance to millions of employees and dependents covered by civil service employee health benefits.
One implication of the impact of Bush appointees on long-term care is that the industry might do better in the policy arena when nursing homes are not receiving a lot of visible attention from the White House and Capitol Hill. During the 1990s, President Clinton personally championed repeal of the Boren Amendment—a change designed to undermine the ability of nursing homes to use the federal courts to enforce cost-based reimbursements. Similarly, previous White House leadership had facilitated passage of OBRA and its restrictive and often punitive regulations. In contrast, the benign neglect practiced by White House staff members under Bush II has allowed experienced officials in Washington to develop policies based in part on recommendations from the long-term care industry rather than on political calculations.
Another implication might be to cast doubt on the utility of continuing the divisions between organized lobbying and other political education by representatives of residential and home-based long-term care. There was a time when home-based care was held up as a preferred alternative to nursing home care, and individuals running for office today frequently tell voters that they support “allowing the elderly to remain in their homes and communities.” The reality, however, is that Congress and the states mostly want to control the growth in public-sector health costs regardless of whether those costs are due to reimbursements for residential or home-based care. When the full spectrum of long-term care unites behind fair reimbursement policies, the entire field wins.
As I have reported over the past several years, the long-term care field continues to face serious public policy challenges. Turn on late-night television and you can see the frightening advertisements of The Law Offices of James Sokolove, the nation's largest and fastest-growing marketer of legal services. Representing more than 300 law firm throughout the United States, the Sokolove firm advises the audience that abuse of the elderly in long-term care “is on the rise” and invites viewers to call if they even suspect that a resident of a nursing homes may have been abused. The ads remind us that the popular image of long-term care remains grim.
For the moment, however, the nursing home field overall appears to be solvent and committed to quality care. Conditions here in Guam remain an exception to the rule rather than a portent of things to come nationwide.
I take some comfort from that in reflecting on my years of writing for Nursing Homes.
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