Texas
Nursing Homes in a
Tight Fix on Medicaid
By BOB MOOS / The Dallas Morning News
March 4, 2009
bmoos@dallasnews.com
Lou O'Reilly thinks Texas is a hard place to grow old. "If, as they say, a society is judged by how it treats its most
vulnerable citizens, Texas comes up short," said the co-founder of
Texas Advocates for Nursing Home Residents. "It's shameful how little
this state does."Life is hardest for Texans who must rely on the state
for their nursing care, she says.
Texas' Medicaid program
reimburses nursing homes an average of $112.79 per patient per day –
less than 48 other states and just 72 cents more per resident than
last-place Illinois. Patient advocates and industry
experts say Texas' 49th-place ranking means that nursing homes often
can't pay employees competitive wages. That in turn leads to high staff
turnover, which can hurt residents' care. It's no
coincidence, they point out, that 28 percent of Texas' 1,100 nursing
homes received the worst rating and only 10 percent scored the best
when Medicare announced its new nursing home ratings late last year.
"Texas is cheap when it comes to Medicaid," said Amanda Fredriksen,
manager of advocacy for AARP in Texas. "The vulnerable – of all ages –
are paying the price because the state hasn't put up the money."
Senior organizations, advocacy groups and industry associations are
mounting campaigns to persuade Texas lawmakers to raise Medicaid
reimbursements this year. The money, they say, should pay for more caregivers, higher wages and better training.
The reimbursements now don't even cover nursing homes' actual costs and
would need to increase to at least $125 a day for facilities to break
even, said Tim Graves, president of the Texas Health Care Association,
an industry group. Despite the growing trend to care for
older adults in their own homes, skilled nursing facilities remain the
most practical option for seniors who become so frail that they require
round-the-clock care. Skilled nursing care costs tens of
thousands of dollars a year, so many nursing home residents eventually
exhaust their personal assets and qualify for Medicaid, the
federal-state health care program for the poor. About two-thirds of Texas' 90,000 nursing home residents are on Medicaid.
"This is the part of the state Medicaid program that reaches well into
the middle class," said Anne Dunkelberg, associate director of the
Center for Public Policy Priorities, a think tank in Austin. "It
touches a lot of lives." Nursing homes struggle to make
up the difference between what they get from Medicaid and what they
spend on patients, said George Linial, president and chief executive of
the Texas Association of Homes and Services for the Aging. Sixty Texas nursing homes have closed since 2006.
"Homes are shifting costs to private-pay patients to balance their
books," said Molly Shomer, a geriatric care manager in Dallas. "Seniors
who are in nursing homes on their own dollar are subsidizing those on
Medicaid." Maintaining the "right mix of patients" is the
key to a for-profit nursing home avoiding red ink and staying in
business, said Dawn Kuser, administrator of the Mesquite Tree Nursing
Center in Mesquite. About 20 percent of her patients are
there for short-term rehabilitation, which Medicare covers at an
average of $250 per day. Ten percent pay out of pocket or through
long-term care insurance. Their average rate is $125 a day, excluding
medications. The other 70 percent of her patients are on Medicaid.
Nursing homes have tried to hold the line on their labor costs, but
that leads to high staff turnover. It's difficult to compete with
hospitals, which pay better, so nursing homes routinely lose registered
nurses, licensed vocational nurses and nurses' aides, according to the
Texas Center for Nursing Workforce Studies. "The average
annual turnover rate is 87 percent for certified nurses' aides," said
Pearl Merritt, who leads a center task force on long-term care. "It's a
challenge to maintain high-quality care in a revolving-door
environment." Working at a nursing home has become far
more demanding as the typical patient has become sicker, said Gary
Anderson, a partner in the Plano-based Preferred Care Partners
Management Group, which manages nursing homes.
"In some markets, nurses' aides can work at a McDonald's for more than
we can pay them," he said. "Some consider their nursing jobs a calling,
but others burn out after a couple of years and look for another kind
of work." Nonprofit nursing homes trying to offset their
losses from Medicaid have one option that for-profit facilities don't.
At Juliette Fowler Homes in Dallas, president Kay Ellis says she's able
to tap her institution's endowment and charitable contributions to make
up at least part of the average $50 per patient shortfall in Medicaid's
reimbursements. "If Medicaid's reimbursement rates were
higher, we could afford to serve more Medicaid patients," she said. The
current wait for a Medicaid bed at Juliette Fowler's nursing home is
six to 12 months. Though lawmakers have raised
reimbursement rates slightly in recent years, Texas remains 30 percent
below the national average of $163.27 per day. State Sen.
Bob Deuell, R-Greenville, vice chairman of the Senate Health and Human
Services Committee, says increasing Texas' reimbursements for nursing
home care could save money for the state over the long term.
"If we can provide better care in nursing homes, we won't have to spend
as much on hospitalizations," he said. "Our rates are too low. I don't
know how much we can raise them, but we'll work on them." Advocates say the federal economic stimulus package could free up state money for nursing homes.
O'Reilly, who's been an advocate for Texas nursing home residents for
20 years, says nursing home employees are underpaid, overworked and, in
many cases, inadequately trained. "They can't provide
good care under those circumstances, and the residents suffer as a
result," she said. "Why, in a state as proud as ours, do we permit that
to go on year after year?" |
