What's Wrong With This Picture?

You've seen the picture - the lonely elderly person sitting in a wheelchair, where the only companion in a lonely hall of look-alike rooms is the cold, clinical flourescent lights. Ask 10 people what they think of a nursing home, and for 7 the first answer will be "it reeks!" Ask anyone, or better yet, yourself, if that is REALLY how you want to go out ... for most the answer is "no way!"

Government regulators and patient / resident advocates see a different picture (I'm going to broad-brush this, so don't shoot me): money-grubbing corporations who short change patient care to feed large bureaucracies and pursue profits. They see this resulting in deficient care, neglect, sometimes even abuse or actual harm to a patient. Take it a step further, and you will actually find health inspectors who are only really concerned with writing "tags" (or in lay language, penalties) for observed deficiencies. Some advocates are SO strung up the line that they refuse to think rationally about their demands of operators.

Operators of facilities can be segmented multiple ways ... some for-profit, others not-for-profit ... some large corporate, some small religious missions ... etc. Regardless of tax status claimed, operators of nursing facilities MUST pay the bills to keep the lights on, staff employed, food on the tables, etc. And the long term care industry isn't a margin rich environment - generally speaking over 2/3 of a facility's reimbursement comes from Medicare / Medicaid funding - and that's a tough business. Most operators live in fear of the state - seriously. Why? Because the state has the self-appointed power to de-certify a facility - they can walk in anytime and slap around the staff however they please with little or no repurcussions. For anything ... if they see something they don't like, they can find a regulation that is violated in accordance to their personal distaste and write the "tag."

Additionally, most for-profit operators exist to feed the monster above them, namely the corporate bureaucracy. It's rife with all the traditional corporate titles ... "regional director of ..." or "corporate vice-president of ..." or whatever. You get the idea. There's a bunch of chiefs sitting up there that need to be fed. So the "administrator" of the facility lives a life not unlike the proverbial whipping boy (or girl) - one minute bending over to take it from corporate, the next minute bending over to take it from the state, the next minute from an unhappy staff member, next from a resident or family member, and so on. Paralyzed. An existence of schizophrenia - who's going to take the next pound of flesh?

Not-for-profits typically aren't much better. We are twitterpated by their warm and cozy mission statements, and somehow "not-for-profit" sounds so ... so noble. But think about it - if their profit margin (revenue minus expenses) is less than zero, where do they get the money to make payroll, buy food and supplies, pay the bills, the rent, the fines, etc.? From what I've seen, any excess margin goes towards feeding a bureaucracy - until you end up in the same dilemma of the for-profit gang - paralysis.

Finally we have our good friends at CMS - yes the Department of Health's fine organization titled "Centers for Medicare & Medicaid Services" (http://www.cms.hhs.gov). Lovely. This is the government division charged with, among other things, dispersing our tax dollars into the hands of providers of medical services for citizens enrolled for coverage in the Medicare and Medicaid programs. They are also tasked with dispersing as few of those dollars as possible, hence the low reimbursement rates, especially for Medicaid programs. But wait, there's more. They are also tasked with ensuring that the dollars do not end up in the hands of fraudulent ilk (this is good), and with taking back as much of the $$ from providers who can't jump thru all the hoops to keep the money (this can be bad).

Got it so far? Let's recap ... state regulators want to enforce the MINIMUM standard that is legally required of nursing home operators. Some regulators want to write as many tags as they can. CMS wants to spend as little money as possible in the rehabilitation or long-term care of our loved ones - in fact they want to take back funds already distributed to facilities for any error they can find. If operators want to keep the money, they gotta jump thru those hoops. Regardless of "for-profit" / 'not-for-profit" status, most organizations have a hungry bureaucracy that needs to be fed off of the earnings of most facilities. So what, Dave?

Yeah, that's the problem. Bureaucracies are so busy trying to get fed by miniscule reimbursement that wise investment in the facility often goes by the wayside. Administrators are so busy trying to please the bureaucracy, or state, or CMS, or whoever, that they don't have time to sit down and think about what would be best for the facility and its residents. State regulators are so busy trying to enforce the MINIMUM standard that the entire industry decides that the MINIMUM is good enough. And who gets the shaft in the process? Exactly - the resident. Our grandparents, or our parents, or our whoever ... they're the ones who get the short end of the stick.

So what's wrong with the picture? Here's everyone SAYING that they're out for the best interests of our loved ones - but most everyone is so pre-occupied with the other players or themselves that noone is paying any attention to where they ought. The system works fine, just not for the residents / patients. That is what needs to change. Big time.

I certainly don't think I have all the answers. I'm sure there are smarter people than me grappling with this problem. But I do have some ideas - some thoughts on the philosophy and models of long term care. Hopefully they'll be taken as just that - ideas from a visionary.