The Big Picture--Dealing with smoke and mirrors

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I grew up in a house full of ashtrays. There was always one on the dining room table. There were more in almost every room. You could even find a couple on the front porch. Five or six more were usually waiting in the kitchen cabinets, just in case. Ashtrays were a necessity because my parents were heavy smokers. In their prime, they could each puff away about three packs a day. They often went through four cartons a week. That's 800 cigarettes.

My parents knew cigarettes were dangerous. Who doesn't? More than 1.2 million people in this country now have lung cancer, mostly thanks to cigarettes. Smokes have also been linked to health problems in the urinary tract, mouth, esophagus, stomach, liver and other body parts. Like most smokers, my parents realized they were ingesting poison. But they were simply unable to stop until they had to. Neither lived to age 65.
While I was spared the habit, some of my sisters are less fortunate. They are already beginning to cough in the same way my parents did, once cigarette tar started choking their lungs. Unfortunately, it's a story that gets replayed far too often. More than a million teenagers take up the habit each year.
I'm not laying out these sad facts to pick on the heartless, greedy people who benefit from the cigarette business. The fact is, it's a legal product. Nobody is forced to smoke.
My point is that some bad habits are tough to break, especially when they become addictions.
So it is with the nursing home industry's gamesmanship with Medicare and other federal payments. While the lawmakers who crafted Medicare generally didn't want it to pay for nursing home care, the program increasingly does. However, it often does so in a backdoor kind of way. We have a lot of facilities and states doing some very unconventional things -- most of which appear to be legal -- to get more revenue from Uncle Sam.
The federal-dollars addiction has also spread indirectly to Medicaid. The Department of Health and Human Services recently outed nine states for goosing Medicaid accounting rules to enhance federal contributions.
Do states and providers know this is an unhealthy practice? Of course.
But given the current vagaries of federal payments, both feel -- perhaps rightfully so -- that they have little real choice.
In a better world, adequate payments for nursing home services would be a given. No one would need to engage in unseemly revenue-enhancement tactics to make ends meet.
But until a more comprehensive payment system is enacted, there's really no incentive to put the proverbial ashtrays away. However, you shouldn't need a Surgeon General's warning to know where the current path leads.

John O'Connor is vice president, McKnight's Long-Term Care News.


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