- The Washington Times - Tuesday, October 17, 2000

Nursing homes are pushing Congress to give them more Medicare funding, claiming that cuts in the program have been instrumental in forcing five major nursing-home chains and hundreds of others into bankruptcy in the last two years.

Congress will decide before it adjourns for the year whether to restore more than $20 billion to Medicare, a federal program that pays for health care for the elderly. Nursing homes would get between $1 billion and $2 billion of that money.

"There is a national crisis out there, I believe, and it's how we are going to care for our young and our old in the future," said Rick Abrams, chief operating officer of the American Health Care Association.

The legislation would restore the funding over the next five years. Both the House Commerce and Ways and Means committees, which share jurisdiction over Medicare, have approved a bill for $21 billion. The Senate's bill, still being considered, would give Medicare $28 billion more.

Medicare and Medicaid the latter pays for the poor's health care account for nearly 90 percent of nursing homes' revenues.

Five of the nation's top nursing-home chains have filed for Chapter 11 bankruptcy protection in the past two years: Vencor of Louisville, Ky.; Sun HealthCare of Albuquerque, N.M.; Integrated Health Services of Owings Mills, Md.; Mariner Health Group of Framingham, Mass.; and Genesis Health Ventures of Kennett Square, Pa.

The 1,800 homes run by the companies are still open, because Chapter 11 allows companies to keep operating while figuring out new payment schedules with creditors.

Thousands of senior citizens recently lobbied on Capitol Hill for more Medicare funding, presenting a petition signed by 30,000 elderly to President Clinton and Congress.

"Those signatures let Clinton know that we wanted him to devote part of the surplus to Medicare" because cuts in the program "really hurt," said John Anderson, a patient at Potomac Center, a Genesis nursing home in Arlington, Va.

But Medicare is not the sole cause of the industry's woes. The number of residents has almost tripled over the last 10 years, the role of the nursing home has changed and the industry is facing a nursing shortage.

And, on the horizon, baby boomers are approaching the age when they may have to enter nursing homes.

Both patients and workers at Potomac Center, a 240-bed Genesis facility in the Pentagon City area of Arlington, are feeling the strain.

From thriving to surviving

Five years ago, the industry was flourishing, with nursing homes making money and investing in renovations and new services. So the industry wasn't concerned when Congress proposed reductions in the rate of growth in Medicare under the Balanced Budget Act of 1997.

The reductions came in the form of a new billing system for nursing homes, replacing one in use since 1983. Whereas homes once billed Medicare depending on each patient's needs, the new system established a fixed, daily reimbursement that was based on average expenditures calculated by the Health Care Financing Administration. The HCFA is the federal agency in charge of Medicare and Medicaid.

The cuts hit nursing homes much harder than expected: The act was supposed to cut $1 out of every $6 spent on Medicare; but the slice was actually deeper, $1 out of every $3.

In 1998, the government spent $14 billion on Medicare through nursing homes. In 1999, that amount fell to $12.7 billion, and this year it is expected to be even lower.

Last year, Congress restored $2.7 billion in Medicare payments that would be paid out over the next three years.

HCFA supported the additional funding last year, as well as this year's legislation.

But other government officials are not.

Laura Dummit, associate director of health financing and public health issues for the General Accounting Office, told the Senate Special Committee on Aging that the industry's woes are "a result of business decisions made during a period when Medicare exercised too little control over its payments."

She also said a study from the GAO, Congress' investigative arm, shows that the new payment plan is sufficient to cover the needs of Medicare patients at nursing homes.

Sen. Charles E. Grassley, Iowa Republican and committee chairman, also has complained about how the industry has spent its money. He has said he is against a bill that would restore nursing-home Medicare payments. But he also has said he would support an initiative that specifies the funds go toward staffing.

"They are very quick to blame Congress for not giving them enough money, but not very forward to take responsibility for spending their money poorly," said Jill Gerber, Mr. Grassley's press secretary. "And it's very rare the cases of bankrupt nursing homes to be actually shut down. Usually, the bankruptcy court just organizes their finances while the residents don't know the difference."

Staffing has certainly been a concern for the industry. A tight labor market paired with a nursing shortage has left homes with sometimes half the nursing staff they say they need.

The number of nursing-home residents most of whom will die there has grown. Last year, homes across the nation cared for 1.6 million elderly and disabled persons, nearly triple the 671,000 residents they had in 1991.

Cutting Medicare

"The number of patients has tripled, the patients are sicker, and our labor costs are ever higher," Mr. Abrams said. "And the regulatory structure continues to be as stifling as it's ever been; in fact, more so."

The Medicaid program pays for the care of nearly 75 percent of nursing-home residents and accounts for 50 percent of homes' revenues.

Medicare covers 10 percent of patients, accounting for more than 20 percent of nursing homes' revenues.

"Any reduction in reimbursement will probably have an impact on the quality of life that the patients have in the nursing facility," Mr. Abrams said. "For instance, inability to maintain the structures … or the ability to keep qualified, good people.

"The nursing community is more than medical care it's social services, activities, diet. As the funds are reduced, these things are squeezed. And it's just not the way that our senior citizens who have given so much to this country should be treated."

But another change in the industry has hurt nursing homes as much as Medicare cuts. They have become increasingly oriented toward medical care and have had to hire expensive doctors and nurses, as hospitals cut their budgets and began dismissing patients sooner.

Nursing home as hospital

The change in the system is evident on the second floor at Potomac Center, where some 60 patients recover from heart attacks, hip replacements or other surgeries.

Medicare pays for up to 100 days of care for about 80 percent of the patients here, who become eligible for the program after three days.

The floor is reminiscent of a hospital, not a nursing home, from the institutional green, blue and pink walls and curtains to the nurses who busily go from one room to another, crossing the tiled floor, pushing food and medicine carts.

Most of the patients here go home within 40 days, but others stay longer.

Nursing homes employ 30 percent to 60 percent more workers than 15 years ago, when they did not have acute-care units. At chains like Genesis, where occupancy reaches as high as 97 percent, it's closer to 50 percent.

The additional staff also has more specialized skills because they must care for the acute-care patients.

"That's the problem," said Lisa Salamon, a spokeswoman for Genesis. "It's people with [acute care] skills, like [intravenous] or respiratory, the things you didn't find years ago because that's what was done in hospitals."

Tuesdays and Thursdays are particularly hectic days at Potomac Center. That is when the new Functional Evaluation Treatment Unit (FETU) makes its rounds. Consisting of almost a dozen doctors, physical therapists, nurses and insurance workers, this group moves from patient to patient, reviewing cases.

FETU is supposed to make the patient-evaluation process simpler by bringing caretakers and patients together to examine their progress.

On a Thursday late last month, one of the stops was the room of Rosemary Rivera and Emma Chambers.

Seven caretakers surrounded Mrs. Rivera, 43, who suffers from lupus. Are the medications working? Can she walk without assistance? Can she dress herself? Mrs. Rivera, with a vulnerable smile, just watched as they flipped through papers and took notes. Although she wanted to go home, she knew she wasn't ready to leave.

That settled, the unit moved on to Mrs. Chambers, 75. Any complaints, they asked. "No, everything is fine," she said. "Are you sure?" a doctor asked, his pen suspended in midair, "I haven't heard that in a long time."

She suffers from gout, diabetes and several other illnesses. When she arrived on the second floor in mid-July, she was oxygen-dependent. By this visit, she was breathing on her own and walking without assistance.

The team decided Mrs. Chambers would go home the following week. As FETU members walked out, the doctor instructed a nurse to stay behind and figure out which medications and equipment Mrs. Chambers needed to take home.

"If she has to call someone and bureaucracy has to be moved, it will take forever," the doctor said as he led the medical team to the next room.

Memory loss

The third floor of Potomac Center is a locked dementia unit. Here 60, mostly elderly patients wander through the halls or sit in their wheelchairs. They suffer from Alzheimer's disease, with their memories and ability to recognize people waning.

"A lot of people here don't even have family," said Miss Salamon. "They have no interaction with the outside world, so the people that work here are their family."

Silence reigns, broken only by nurses chatting and the ramblings of a lively woman in a wheelchair, who occasionally waves her hands as if they would help her convey her words.

Most patients here blend in as they sit in their chairs, shoulders dropping, dozing their days away. But there is always a talker. In this case, it's Dorothy, a seemingly vivacious black woman in a wheelchair parked along the wall.

"Thelma, I told you to hurry up," or "Thelma, you're such a good little girl" and other exclamations pour out of Dorothy, who otherwise remembers nothing. Thelma, the nurses say, was Dorothy's younger sister she took care of when they were children. Thelma died some 20 years ago.

Dorothy's husband is one of the rare visitors to the floor. A resident of the nursing home's long-term-care unit, he visits his wife when their nephew and niece stop by occasionally. Until a month ago, Dorothy could recognize them.

Leatha Washington, the unit's director, pointed to different doors and shared the stories of some of the floor residents. Miss Washington used to work at a hospital, but once she realized her love for Alzheimer's patients, she joined the Potomac Center.

Compared with Miss Washington, who started at the nursing home in November, most nurses have worked at the unit for close to 10 years. Consistency is important when dealing with dementia patients because they are able to tell if a new person comes to feed or change them. Then they become upset and sometimes violent.

The traditional nursing home

The smallest things a compliment, a greeting or smile can brighten a patient's day. And that's Rhonda Ashby's job as director of activities.

The energetic native of Barbados started at Potomac six years ago. Today, both her 10-year-old daughter and her miniature dachshund Brownie are also members of the "household."

A job at a nursing home is not for everyone. You must really like the elderly, she said.

"They've lived through two World Wars and really just lived it all. They are like my grandmother, and she no longer is, so … " Ms. Ashby trailed off. "They are wise and you learn a lot from them."

But it's hard work. "But it's expected. You deal with them on their level. I don't try to bring them to my world."

Last year, she got a puppy and started bringing it to the office. The day Brownie met John Hubbard, "he saw her, and that was it. Love at first sight," Ms. Ashby said. Mr. Hubbard is one of 120 long-term residents who are here for the rest of their lives. Some are in their 70s through 90s, but others are as young as late 40s.

At lunch, the residents gather by twos or fours in a sunny and spacious dining room. Mr. Hubbard and two women joke at the prospect of their home being in the news.

Mr. Hubbard, the two women and other Potomac patients attended the Capitol Hill lobbying effort.

A quadriplegic, Mr. Anderson lives at Potomac's acute-care unit although he is a long-term patient. He came here five years ago after he suffered an accident that left him with a spinal-cord injury.

A soft-spoken man with glasses, Mr. Anderson, 69, is known to everyone at the home. He is a public notary and serves on a resident council, communicating residents' needs to the home's administration, the state and insurance companies, Medicare and Medicaid programs.

Recently, Virginia health care regulators spoke with Mr. Anderson as part of their yearly visit to Potomac.

"They could see it wasn't anything staged," he said. "[The home] needs more people, more employees."

Mr. Anderson planned to go to the Hill a few weeks ago. But he missed the shuttle bus because no one helped him get to the lobby.

"It's very, very frustrating when you can see they are short-staffed," he said.

"When I had surgery a few years ago and saw all those people my age there …," he trailed off. "Looking at all the people out on the street who don't even have that I really feel some money could be taken from the top and put into programs like Medicare and Medicaid.

"There are people here who have nothing but Medicare to depend on," he said.

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