Today many nursing homes become luxury-oriented without focus on long-term care at end of life. A report released in 2014 by the Department of Health and Human Services found that about 22 percent of patients have experienced one or more injury while receiving treatment in nursing homes. According to Dr. Arif Nazir, a professor of clinical medicine at Indiana University, many patients are forced to abandon treatment before the infection is resolved. This phenomenon occurs since Medicare policy, health insurance program for older people pay to each of the short-term patients 84 percent more than they used to get from Medicaid.
Even as nursing homes are busily investing in luxury living quarters, however, the quality of care is strikingly uneven. And it is clear that many of the homes are not up to the challenge of providing the intensive medical care that rehabilitation requires. Many are often short on nurses and aides and do not have doctors on staff.
A report released in 2014 by the Department of Health and Human Services’ Office of the Inspector General found that 22 percent of Medicare patients who stayed in a nursing facility for 35 days or less experienced harm as a result of their medical care. An additional 11 percent suffered temporary injury. The report estimated that Medicare spent $2.8 billion on hospital treatment in 2011 because of harm experienced in nursing facilities.
“These nursing homes were not built for this purpose,” said Dr. Arif Nazir, an associate professor of clinical medicine at Indiana University who studies geriatrics. He said many patients leave hospitals with acute medical needs, before infections have been fully treated, or as they adjust to new medications.
“These patients are leaving the hospital half-cooked, and believe me, the latter part of the cooking is the hardest part,” he said.
Competition for these patients has become intense because Medicare, the health insurance program for older adults, pays 84 percent more for short-term patients than nursing homes typically get from Medicaid, the health insurance program for the poor, for long-term residents.
At the same time, hospitals are trying to cut costs by pushing some patients out early — like those who have had hip replacement or heart surgery. Not quite ready to go home, they need continuing care somewhere. And for older adults, Medicare usually pays the bill.
A Bull Market
The combination of factors has created a bull market in the once-struggling industry as investors clamor to snatch up homes with the most potential to bring in short-term patients. Sale prices of nursing homes averaged $76,500 per bed last year — the second consecutive year of record-breaking prices, according to Irving Levin Associates, which analyzes the senior housing market.
So lucrative are Medicare payments that some homes do not take lower-paying Medicaid patients at all.
The shifting landscape, some say, marginalizes poor long-term residents with extensive medical needs. “This focus on Medicare, Medicare, Medicare has pushed out people in the custodial care world,” said Anthony Chicotel, a staff lawyer at California Advocates for Nursing Home Reform, who says he fields calls at least once a week from residents who are being evicted because their Medicare coverage, which lasts 100 days, is expiring and the residents will transition to lower-paying Medicaid. “They’re being pushed out, and they don’t have anywhere to go, really, that can take care of them.”
Representatives of nursing homes acknowledge that the challenges are substantial, but they are optimistic about the progress they are making.
“It’s uneven, but I think, that said, we’re trending in the right direction,” said Dr. David Gifford, the senior vice president of quality and regulatory affairs at the American Health Care Association, an industry trade group. “I think you’re seeing a much greater linking of quality, and an emphasis on it,” he added.
Dr. Gifford and others say they are paying close attention to quality — not only because it is the right thing to do, but also because hospitals and large health systems are beginning to demand it. Under the new health care law, hospitals may be penalized if too many of their patients are readmitted within a certain time.
“Hospitals are starting to get really worried, and when hospitals are worried, skilled nursing facilities are worried, because they are their sources of patients,” said David Grabowski, a professor of health care policy at the Harvard Medical School.
Promises of Care
Dr. Lois Johnson-Hamerman, a retired neonatologist, said she thought she had done her homework when she checked into the Watermark at Logan Square, a nursing facility in Philadelphia.
The home had a reputation for quality and got high marks from the federal government. Until a recent revision, its website promised “top-notch health care” with amenities including a staff willing to administer a “decadent hot bath” at any hour of the day.
But just one month after arriving at Watermark for short-term rehabilitation of an injured foot in 2012, Dr. Johnson-Hamerman ended up in the emergency room with a severe bedsore that had become dangerously infected. Far from the service she said she had been promised, she said the workers never gave her a full bath or shower, were slow to respond to her requests to have her diaper changed and did not turn her every few hours, a crucial step in preventing bedsores.
She said she left the facility only after friends, including doctors and nurses, insisted that she be taken to a hospital.
Geriatric researchers call this disconnect the “chandelier effect.” Attractive lobbies and enticing amenities do not always mean that a home provides good medical care.
In reality, said Dr. Steven Handler, a geriatrician and assistant professor at the University of Pittsburgh School of Medicine, many nursing homes are struggling to provide consistent, quality care despite genuine efforts. “The nursing homes are kind of stuck in an older model that is based on a very small operating margin, low-staffing model and low physician presence,” he said.
Dr. Johnson-Hamerman, who is 87, is suing Watermark over what she describes as negligent care.
“At least I’m still here,” she said recently at her home. “But where would I be if I didn’t have the friends and resources to do something about it?”
C. Jill Hofer, a spokeswoman for Watermark, said that the home was committed to providing quality care and that it denied the lawsuit’s allegations.
The nursing home industry has long argued that it relies on higher Medicare payments to offset the rates it receives from Medicaid, which usually pays for the care of long-term residents.
And indeed, even though facilities earned a 2 percent overall profit in 2013, they lost about 2 percent on non-Medicare patients, according to the Medicare Payment Advisory Commission, or Medpac, an agency of Congress.
But in recent years, that focus on Medicare patients has intensified as many long-term residents have moved to assisted-living facilities and hospitals have sought to discharge patients earlier. On a typical day in 2000, about 9 percent of residents in an average nursing home were covered by Medicare, according to federal data. By 2014, that had risen to 15 percent.
Some companies are now eliminating Medicaid payments entirely by building homes solely for the more lucrative short-term patients.
Santé Partners, a developer in Arizona, recently opened four nursing homes that do not accept any long-term residents. A fifth is set to break ground this summer.