I became aware today of a Brown University study that estimates the current Trump tax cut bill will close about 580 nursing homes. Since the average nursing home has about 109 beds that means 63,220 people will be out on the street or worse. Where do politicians (more specifically the Republican party and their constituents) think these people will go? And why don’t they seem to care?
Over the course of my career – I have probably been in at
least 50 different nursing homes in Wisconsin and Minnesota. The care I have observed in most of those
places is managed to be adequate to barely adequate. By that I mean like all businesses they are
managed to make money. Unless they are
privately financed by a foundation or high paying patients, that typically means
there is minimal staffing and the most qualified people are typically RNs who
spend most of their shift managing medications and medical problems. That can mean long waits for medicines or
care. It can also mean that behavioral
problems like agitation or overt aggression are allowed to escalate to a
dangerous point.
When I first started doing assessments in nursing homes it
was 1986. In those days, there were very
few diagnoses of Alzheimer’s Disease (AD) or vascular dementia (VaD) since the
NINCDS-ADRDA criteria were not widely known.
Most of the people I was seeing had diagnoses of arteriosclerotic dementia,
arteriosclerosis, or hardening of the arteries. At some point
very early in this timeline, there was an initiative to make sure that old
people with psychiatric diagnoses did not get admitted to nursing homes. But like all political initiatives it was not
always an either-or situation. I would frequently
see people with schizophrenia and bipolar disorder who had developed AD, VaD, Parkinson’s
plus syndromes, or tardive syndromes in addition to the primary psychiatric disorder. In many of those situations a subsequent rule
about tapering antipsychotic medications to prevent oversedation and associated
morbidities became a problem because of the need for maintenance medication.
Psychiatric services are needed in nursing homes for all of
those reasons but they are rare.
The reason they are rare is funding – specifically rationing psychiatric
services by both Medicare and Medicaid. I ran a Geriatric Psychiatry and
Memory Disorders Clinic for a decade and we eventually closed because we
could not maintain an adequate work quality and get adequate reimbursement. For
a time, my clinic nurse and I decided to go out into nursing homes and see
patients there to make it more convenient for patients, families and staff and
see if it made a difference. We were reimbursed at an even lower rate for those
efforts. My speculation is that most of
the psychiatric care and treatment in nursing homes is done by nonpsychiatrists
and probably nonphysicians. This in part
is an additional reason for low quality care in most nursing homes.
Let’s consider the impact of all of these nursing home
closures. First, it will greatly add to the current burden of emergency
department (ED) congestion. There is
always a steady influx of nursing home patients to the ED with new diagnoses
(pneumonia, urinary tract infections, cellulitis, etc). With further reductions
in staffing, it may be more difficult to get them back. I can recall one of my social work colleagues
calling 22 different nursing homes one day to discharge one of our stable
patients. None of them would accept that
patient. We were under intense pressure from the hospital at the time to discharge
that patient because we needed to admit patients from the ED. That whole chain of events will get worse –
not the least due to the fact that far fewer nursing homes will accept people
who have been admitted to an acute care psychiatric unit. There will be backups
all around – on inpatient units and in the ED.
The same chain of events will occur on medical and surgical units who
often put pressure on psychiatry to take their “stable” nursing home patients
who may have a psychiatric disorder.
There will also be a steady-state of patients bouncing in
and out of the ED-inpatient psychiatry or medicine-discharge sequence. This is a familiar pattern in many hospital subpopulations
that usually occurs because of a lack of adequate housing. Expect to see more elderly nursing patients captured
by this cycle.
Will there be excessive mortality and morbidity? Of course there will be. In the course of my career, I had to discharge
patient to nursing homes where I knew they could not get the level of care they
got on my inpatient unit. I worked with highly skilled RNs – 4 on the
day shift, 3 on the evening shift, and one on nights with 3, 2, and 2 nursing
assistants respectively covering 20 beds. We cared for patients with complex
medical problems that required frequent monitoring and intervention. I knew there was no nursing home that I could
discharge them to where they would get the same level of care and that would be
a problem for them.
I have also walked in to a nursing home and seen the results
with my own eyes. I recall visiting a 92 yr old woman with congestive heart failure
and hypertension. She was obtunded,
cyanotic, and barely responsive. When I
asked the staff to check her oximetry and start oxygen they produced a nursing supervisor
instead for a discussion. When the
oximetry was finally done it was 60% and she regained a normal conscious state
with oxygen. The assessment I made only
required knowing this patient’s baseline state and asking what had happened
given her chronic conditions. Is that
too much to ask in the case of nursing home staff?
In another more recent case – a 92 yr old man had C.
difficile colitis following extended antibiotic therapies for post COVID-19 pneumonia. During that time his body weight went from
130 to 87 lbs (he was 5’11” tall). He
was weak and barely able to ambulate. Despite the C. difficile diagnosis there
were no infection
control precautions and he shared a bathroom with 3 roommates. Despite his clinical status (barely able to walk unassisted,
not able to eat, BMI of 12.1) the insurance company paying for his care insisted
that he be discharged home under the care of his family where he died the next
day.
Both of these cases are examples of low-quality care. Rationing care is the most likely reason. In one case the rationing is implicit (low
staffing based on the need for profits from reimbursement) and explicit (inappropriate
utilization review decision). It all
comes back to reimbursement.
A final consideration is that the funding cuts go far beyond
nursing home care. The most
conservative estimate I have found is that the cuts would increase the
number of uninsured by 7.8 million people and reduce Medicaid enrollment for
10.3 million. Hospitals are legally
obligated to treat all people with acute care conditions whether they have
insurance or not. That means that many of these people will be in the
ED-inpatient-discharge steady state cycle taking up beds. They will also more likely be acutely ill and
spend more time in the hospital. All of
that care is unreimbursed. That means
higher health care costs and premiums for everyone. One projection is a doubling of
premiums. This is essentially another
tax on the average American who is just trying to break even. All of that is to provide tax cuts for billionaires
and businesses while still incurring a 3-5 trillion dollar deficient.
It also means less access to hospital beds when you need
it. I have illustrated
on this blog what can happen when you don’t have timely hospital bed access
for what is considered a routine condition.
In the final analysis, nursing home care in the United States
is seriously rationed care. Although there are some high-end nursing homes that
require additional reimbursement and provide more supportive environments most
are not operating at that level. They
provide the basic function of providing care on a 24/7 basis to a severely
disabled person that the family cannot care for. Even that is a recent concept in American society. As an example, one of my elderly ancestors
had a closed head injury as a result of blast injury. He lived at a time when
there were no nursing homes in his area only a poor farm, that cared for
the indigent and poor elderly. He had a
problem with severe aggression and would routinely wreck all of the furniture
in the house. I never learned how they were able to contain this behavior, but
the modern question is whether this is an acceptable standard for families. Can family members be expected to contain
severe aggression from a family member with dementia and keep everyone safe? I don’t see how.
Severely rationing of health care in the bill being debated hurts us all…
George Dawson, MD, DFAPA
Photo Credit: Thanks to Rick Ziegler for the thunderstorm photo.
