The Atlantic recently posted an article called “How to Fix Nursing Homes.” It’s a well-written and thoughtful piece. My only gripe is that the headline is a bit of a reach.
The story gets quite a bit right. For example, it notes that the field is heavily regulated, risk averse and fearful of lawsuits. It’s time for regulators to lighten up already, the author rightfully insists.
But at its core, this is not truly an article about fixing nursing homes. It’s really more of an advocacy piece against institutional care.
Certainly, culture change is a necessary and important step toward better nursing home care. Fortunately, many operators have bought in to this more enlightened approach to delivering care and services. But if the topic is fixing nursing homes, culture change is only part of the answer.
It’s worth remembering that nursing homes did not arrive fully formed from an alien planet. The nursing home business as it now exists is largely the residue of landmark Medicare and Medicaid legislation passed in 1965. Like so many other package deals, nursing home coverage required compromises.
The idea behind publicly-funded eldercare was and is a noble one. But as lawmakers tallied the cost of Medicare-only nursing home coverage, they were hit by a sobering reality: There was simply no way to pay the bill in full. The result was an adjustment that allowed many shoddy facilities to remain in business more than four decades later: Medicaid would reimburse facilities for most of the care. In other words, nursing home coverage would become a welfare service, not an entitlement.
Why is nursing home quality often bad? For the same reason that the quality of items purchased at a discount store is often poor: The seller and buyer are focused almost entirely on the lowest possible cost. In order to subsist on a Medicaid diet, operators had to keep the frills to a minimum. Even today, when more generous Medicare funding abounds, the old keep-costs-down-or-else mindset persists.
Actually, some operators have ignored this economic imperative. Instead, they have spent more on staffing, food activities and other amenities, in an effort to deliver a higher quality experience for residents. These places even have a name: assisted living communities. However, they are essentially a private-pay option. For many seniors, that means they are simply not an option.
In senior care as in so many other things, you get what you pay for. If we as a nation want to improve nursing home quality, the answer is simple: Pay operators more. Yet, all indications are that just the opposite will happen.
Requiring operators to do more with less is hardly a recipe for improvement. In the case of long-term care, it’s a recipe for disaster.
