Letter to the Editor

Letter to the Editor
Stephen A. Smith
President, Indiana Health Care Association


The article entitled “Crisis of Care” that appeared in the Sunday, March 7th edition of your paper suggested the care provided in each of Indiana’s for-profit nursing homes was suspect, due entirely to their motivation to achieve an economic gain. IHCA agrees that there is a “crisis of care” in Indiana nursing homes, but implying that the “for-profit” nature of the majority of the providers engaged in providing this type of service is the cause is simply misleading to your readers. The fact that 52 Indiana facilities appeared on the GAO list of poorest performing nursing homes should be a call to action for all stakeholders, not just the for-profit nursing home operators and ownership groups.

What if the “crisis” being described in your story referred to education and not to nursing home care? If you were the parent of a student who was in a class that had the highest failure rate, lowest graduation rate, or lowest test scores of any school system in the country, you would not immediately assume that all of the students were failing, you would assume that the system was failing the students. You would also not assume that the issue would be resolved by providing fewer resources to the failing schools or limiting their options to resolving the issue. However, this is exactly what it taking place in Indiana nursing homes.

For-profit nursing homes in Indiana serve a higher proportion of low-income patients than non-profit nursing homes and are reimbursed less for providing that care. In fact, approximately two-thirds of residents of for-profit nursing homes in Indiana utilize Medicaid to pay for their care. In addition, for every 100 nursing home residents who utilize the Medicaid program to pay for nursing home care in Indiana, 89 are residents of for-profit nursing homes. Medicaid reimbursement currently falls short of meeting costs for these residents by an average of $7/day. In part this is due to an arcane and complex reimbursement system that limits the amount a nursing home can be reimbursed for staff costs, exactly the issue that was cited as the core of the “crisis of care”.

These financial conditions contribute significantly to Indiana having turnover rates for nurses and certified nursing assistants (CNA) that far exceed the national average. Over 90% of all Indiana CNAs change jobs – on average – each year. This undoubtedly has an impact on patient care, but finding a direct solution to this problem will not occur until all stakeholders agree that staff turnover is the real issue to improving the quality of care, and offer real, common sense solutions to reduce staff turnover and improve staff retention. This will require a departure from the historical response of penalizing the providers of nursing home care. Reducing the amount of resources available to solve the problem will obviously not solve the problem.

Finding these solutions now is critical for two reasons. First of all, as we are constantly reminded in the press, the proportion of our population considered “seniors” will roughly double in the next 25 years, and will undoubtedly put an additional financial strain on the long-term care system in Indiana. Second, assuming a staff-to-patient ratio of roughly 1:1, there are over 40,000 Hoosiers employed by nursing homes statewide, a total that now exceeds the number of employees in the state’s automobile industry. Without securing the financial future of these employees we will see a continued erosion of financial conditions in many areas of our state, especially in some rural areas where the local nursing home is one of the largest local employers and economic generators in the community.

There is a genuine crisis of care in Indiana nursing homes, and this is most obvious to the nursing home owners and operators. To focus entirely on for-profit nursing homes ignores the symptoms of the problem and places blame disproportionately on one of the many stakeholders in the process. All stakeholders must be held accountable in order for real reform of the system to occur.

The vast majority of Indiana nursing homes provide a loving, caring environment that maintains or improves the quality of life of their residents. The best way for someone to choose – or evaluate – an Indiana nursing home is to visit one. According to AARP, “The most important element of the selection process, according to the experts, is a personal visit—preferably more than one—to any nursing home you’re considering”. Medicare’s “Nursing Home Checklist” is based almost entirely on a personal visit, and makes no mention of Five-Star ratings, GAO reports, or state survey results as part of their evaluation criteria. The reason is simple: People are the most important part of nursing home care and you can’t experience the people without experiencing the place.