A tipping point for senior care in the North Country

It appears to be pure accident that Adirondack Health announced the elimination of sixty long-term nursing home beds at Uihlein in Lake Placid, just as Essex County supervisors were preparing to vote today on the likely sale of the Horace Nye home in Elizabethtown.

Accident or no, the two events should be a wake-up call.

The long, steady erosion in government and taxpayer resources for elder care in New York State has reached a tipping point, at least here in the North Country.

For years, Medicaid reimbursements have been far too low to pay for the rising costs of those people — the old and the infirm — who need the sort of intense, nurse-assisted care that these facilities provide.

Adirondack Health, based in Saranac Lake, is losing more than $1 million a year on the Uihlein facility.  Essex County is losing $2 million annually at Horace Nye.

That kind of red ink is clearly unsustainable.  And it’s time to talk honestly and bluntly about what that means.

Chandler Ralph, CEO of Adirondack Health, did that yesterday.  She said point-blank that in future many poor, Medicaid-eligible people will be turned away from Uihlein.

“We will still take Medicaid recipients, but it won’t be all comers like it is now.  We can’t afford it,” she said.

And in fact, the situation appears far more serious than that.  Of the 60 remaining beds at Uihlein, 15 will be used for people in short-term rehabilitative care.  That leaves just 45 beds for all long-term nursing care in Lake Placid.

It seems likely that many of those beds will go to people with independent means, folks who can afford to pay far more for their care than Medicaid.

In Essex County, meanwhile, the conversation has been less blunt, less clear.

Town supervisors have suggested that the for-profit company that is expected to take over Horace Nye would continue to accept the poor, high-needs Medicaid patients who drive up costs without bringing in much revenue.

But why would they?

If a well-run, efficient, locally-rooted non-profit like Adirondack Health can’t make the numbers work — with salaries and benefits for staff already well below those offered at Horace Nye — why would a New York City-based corporation take on those kinds of residents?

So if I’m right — if in the very near future there are simply far fewer beds in our region for low-income elderly people with dementia and other serious medical needs — what happens to them?

In her comments this week, Ralph suggested that families in the North Country will have to do far more to care for their own seniors.

That won’t be easy in an age when everyone has to have a job — sometimes two or three jobs — to make ends meet.  This isn’t the 1950s, when Mom could afford to stay home to look after the kids and grandpa.

To help families cope, Ralph called for creation of a new, better integrated network of service providers that might help people remain comfortable in their homes much longer.  It’s a creative and compelling idea.

But as Ralph acknowledged, that effort is just getting underway.  The first organizational meeting is scheduled for next month.

And particularly for the truly poor in the North Country, these developments at Uihlein and Horace could mean real, painful and immediate changes — right now.

In the weeks and months ahead, many families will find that there are simply fewer good options when a senior finally reaches the point where they need nursing care.  For some there will likely be no good options anywhere close to home.

There’s a saying that you get what you pay for.  And right now, this is the safety net for the elderly that we’re willing to pay for.

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76 Responses to “A tipping point for senior care in the North Country”

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  1. Paul says:

    Even if you have the money it is almost impossible to find good in-home care in some NC areas. I am speaking (typing actually) as someone who is dealing with this issue right now.

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  2. Kathy says:

    Two observations:

    Town supervisors have suggested that the for-profit company that is expected to take over Horace Nye would continue to accept the poor, high-needs Medicaid patients who drive up costs without bringing in much revenue.

    But why would they?

    Maybe someone isn’t just looking at the numbers.

    That won’t be easy in an age when everyone has to have a job — sometimes two or three jobs — to make ends meet. This isn’t the 1950s, when Mom could afford to stay home to look after the kids and grandpa.

    Not all have jobs in order to make ends meet. At times, it’s a matter of priority. I wonder what the percentage is of seniors who are currently in nursing homes – who could be living with extended family?

    Hot debate. Like/Dislike Thumb up 2 Thumb down 5

  3. JDM says:

    “The long, steady erosion in government and taxpayer resources for elder care in New York State has reached a tipping point”

    “Medicaid reimbursements have been far too low to pay for the rising costs of those people”

    Here in realityville, we have the true answer for those who think government-run health care is way to go. It is an utter failure.

    Hot debate. Like/Dislike Thumb up 2 Thumb down 9

  4. Brian Mann says:

    JDM – What does your realityville look like? If a poor, two-working person family has a senior with dementia and advanced medical needs and can’t afford to pay the going market rate at a for-profit care facility, what will they do?

    –Brian, NCPR

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  5. Maggie says:

    I can tell you it’s hard enough with two people working- I’m an RN and I couldn’t care for my mom at home and had no choice but Horace Nye- I feel sorry for the future, poor elderly when they have no where to go because a 2/3 majority of Supervisors felt the grass was green, mowed & the birds were chirping at the privately owned facilities they visited. Who’s going to provide the care??? Hospitals- at a higher rate than a nursing home. Short sighted, irresponsible decision

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  6. Peter Hahn says:

    JDM – This is not government run health care, it is privately run health care. But it is a government failure; it is a failure to properly care for the elderly. This is also a really bad omen for the future care of the elderly poor. In the old days, medicaid reimbursement was high enough that institutions could care for recipients of medicaid and not lose so much money that they would go broke.

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  7. knuckleheadedliberal says:

    With global warming we don’t even have ice floes to put our elderly onto anymore.

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  8. mervel says:

    But I think this is the future of government supported health care without cost reform. Nursing homes are just part of the health care continuum, unless there are significant changes to the current laws, in particular the new health law which kicks in next year, this is what is going to happen to rural hospitals.

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  9. mervel says:

    The problem is not how we are paying, public, private whatever, the problem is that medical services in the US are grossly more expensive than in other countries where government financing works.

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  10. TaxCap says:

    What will happen is the medicaid patients will end up in hospitals that, legally, cannot turn them away. Yes, it will be higher cost. You will pay for it in higher medical bills, or higher insurance premiums, instead of via your real estate taxes. But you will be paying for it, just as you are now.

    This just shifts the costs from real estate taxes to the hospital system. And the net will be higher costs.

    Until we get universal care, either via gov’t run health care or via the hated individual mandate, the system will just move medicaid patients around.

    The tax cap forces stuff like this….and I’m sure there is more to come.

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  12. Paul says:

    I know this is dangerous territory but I will try to defend JDM’s comment. Brian the point may be, not that folks don’t need and or deserve care, but that the public sector (in this particular case) has failed. It is not useful in the discussion to try and demonize someone who comments (albeit in a strange way) that the system has failed and expanding that model to the other areas may not be a good idea (a debatable point).

    In the NYT article I supplied yesterday they describe that even in most European countries where there is government run systems set up to pay for this type of care they are still sending nuns out to take care of poor old people that need it and can’t get into a state run facility. It is basically sounds like what the AMC (or whatever it is called now) director talked about how we will have to find alternatives for people.

    Many doctors are no longer taking medicare patients. Not because they are mean but because if they go broke they can’t take care of ANY of their patients. That system is broken as well.

    This real problem for the North Country is that there is far too little business activity and therefore very little tax revenue.

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  13. Paul says:

    We have the Trudeau tipping point, now this one. Seems like everything up there is “tipping”.

    Like/Dislike this comment: Thumb up 3 Thumb down 1

  14. JDM says:

    Brian Mann: “What does your realityville look like?”

    Real health care reform. Big government medicare/medicaid solutions don’t work in realityville.

    Health care doesn’t have to cost an arm-and-a-leg. It will until realityville changes are made. Tort reform, mandates, and health savings are a few really good starts.

    Every lib here will pooh pooh those three suggestions. Well? We’ve seen the failure of the big government solutions. Let’s give these a try. If they fail as badly as what we have, we will all have to look for other solutions.

    To date, my realityville solutions have not been tried. They are pooh-poohed, but not tried.

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  15. Walker says:

    The U.S. hasn’t tried the French system either, JDM. That’s another reality.

    [At this point, Mervel will say "Yes but out costs are too high to do that." To which I can only say, "Then we will have to work towards it gradually.]

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  16. Walker says:

    Look the real key to our costs being too high is Fee-for-Service, rewarding physicians for over-treating patients. We need to reward physicians for health outcomes instead. The AMA is almost certain to fight any such change, but more and more the AMA does not represent the majority of doctors.

    I don’t know… I truthfully don’t see how we’ll ever get anywhere with healthcare or any of our other pressing problems until we get money out of politics, and I can’t say I’m especially optimistic that we are capable of doing that. But that’s where it has to start.

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  17. mervel says:

    We need to take a hard look at how to re-design our health care system to be much less expensive. I think it is worth it, but it would have to start with the cost of medical education and how that is financed, the cost of billing per procedure versus per pateint health, the cost of liability insurance and the huge pay inequities between a specialist and a GP who is the gatekeeper to the entire system.

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  18. mervel says:

    As someone who in general does support the free market why would I say we should re-design an entire industry? Well the reason is that the health care industry is already a government funded program, our current system has very little to do with the private market.

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  19. Larry says:

    The root cause of health care problems is runaway costs, many of which are unnecessary. Until that is brought under control we haven’t a chance of providing equitable and affordable care for all. Doctors can cry all they want but they are at the heart of the problem.

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  20. Peter Hahn says:

    There is a big government role,in health insurance via medicare, but not so much in the health care that most working people get. That is currently run as a free market system. That’s for profit, and it shouldn’t be a surprise that cost are be driven up as long as decisions are by the doctor/patient. That’s like going in to the store and buying whatever the salesman recommends because someone else pays.

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  21. CJ says:

    We can spend billions on killing people in wars that very few support but we have trouble taking care of our seniors…sad

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  22. mervel says:

    Larry not all doctors are the heart of the problem, not the most important doctors who are our GP’s and so forth the people we actually see. They are not overpaid. I think the average is around 90k for those guys, for what they do that is not much money. It is less than most school administrators in the NC make for example.

    The overpaid guys are the specialists who we never see but just get the bills, and that is why there is a shortage of doctors for normal people to get an appointment with.

    The fact is though everyone in the health care industry is going to have to make less, from the ceo’s of health insurance companies and drug companies and overpaid drug salesmen to nurses and doctors, they are all going to have to make less for this system to be affordable. All of those people make less in places like France that has a good system that is affordable.

    I don’t see it happening the industry has too much power as witnessed by the Obama health care plan which keeps the gravy train rolling.

    Like/Dislike this comment: Thumb up 3 Thumb down 0

  23. Paul says:

    “that is why there is a shortage of doctors for normal people to get an appointment with”

    Wait a minute is this true? If it is what will happen when we add many millions more people who will be getting primary care under the “affordable care act”? Did we take this into account before we passed this legislation? No we didn’t bother to figure this out, doctors don’t grow on trees. Care is going to get worse before it gets better.

    Like/Dislike this comment: Thumb up 1 Thumb down 2

  24. oa says:

    I am going to include myself in this, but I seriously doubt there is a single person on this comment thread who has even the vaguest idea what they’re talking about. And I think that’s a big part of the problem with the medical system in this country. We have met the enemy, etc…

    Like/Dislike this comment: Thumb up 4 Thumb down 2

  25. Pete Klein says:

    We as a species are totally insane.
    Modern medicine keeps coming up with ways to make people live longer. These ways cost more and more money. Then we complain how much it costs to keep grandma and grandpa alive. But we insist they must be kept alive for another month, week or even a day – no matter what it costs.
    Most of us say we are Christians and believe in an afterlife. But if this is true, the way we act about death would seem to indicate we expect grandma and grandpa to go straight to hell once they die so we must spare them eternal damnation for as long as possible.
    If this isn’t insane, I don’t know what is.

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  26. Paul says:

    oa, I dont think I made any comments here that I think are clueless? Maybe? What do you mean?

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  27. mervel says:

    Paul is correct you can’t mandate supply. Until we totally change the cost structure of the system if you try to go with our current legislation we will see health care harder and harder to find.

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  28. Paul says:

    Pete, I read a great article in Scientific American recently that taks about how our propensity toward science, art, creativity, etc. is based on our realization that we have a limited time here, as opposed to other creatures that do not understand this. As a writer I think you would like it.

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  29. Paul says:

    Sorry, “talks” not “taks” (iPad typing)

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  30. mervel says:

    Oa but I think the opposite is true. We have spent too much time not looking under the hood at healthcare, trusting the so called experts at the insurance companies and drug companies and hospital executives, and yes even doctors.

    Its time we all started asking questions and demanding answers from the whole industry.

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  31. Larry says:

    OA, you may be right about yourself but you ought to stop right there. This is supposed to be a debate and exchange of ideas and one need not be an expert to participate. And no, mervel, I do not think all doctors are part of the problem. I am sure that there are conscientous, dedicated doctors who are motivated solely by the desire to help their fellow man; I just don’t know of any. There is systemic financial chicanery at all levels of the medical system.

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  32. zeke says:

    JDM, What specific tort reforms and mandates. Also, how specifically will these savings accounts work? Specifics please. After all these are YOUR “Realityville”(?) solutions.

    Like/Dislike this comment: Thumb up 4 Thumb down 1

  33. Peter Hahn says:

    you have to “mandate” supply (ration) and make sure the supply goes to those who most (medically) need it. Demand is elastic and can expand indefinitely.

    Tort reform can reduce malpractice insurance costs which used to be a pretty big component – maybe 10% – of health care. It is now much smaller since all the other costs have gone up so much. And – some of that is necessary – there are actual malpractice errors and somebody has to pay for those. In other words – Tort reform could reduce health care costs by a couple of months worth of health care cost inflation.

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  34. Peter Hahn says:

    And we have savings accounts now. Thats a great system for out-of pocket type expenses if you have a lot of money and can shelter some of it for that purpose. But if your doctor recommends that you need some procedure, you arent going to quiz him/her about whether there is a cheaper procedure, or go looking for a doctor who will do it for less money. You arent going to imply that he/she is only recommending this procedure for the money.

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  35. mervel says:

    I think we are assuming though that there will be a supply to ration.

    So under current medicaid billing rates, this nursing home can’t make it what will happen when government billing rates go down even more with the health care reform? Health care reform won’t work without changing how we provide services and at what cost.

    Larry, of course physicians have some financial interest, they can’t afford to work for free. Most are laboring under substantial debt from spending 20 years in school (which is part of the initial cost problem), then they have to pay to run an office, plus of course all of the insurance they have to carry, plus they work a lot and it is high stress. That is the reason that so few doctors go into general practice and the reason that we have a supply problem at the front end.

    One solution would be to reduce the costs of being a doctor. For example in France where doctors make what our better paid nurses make here, medical school is largely paid for and they don’t have the huge liability issues.

    The fact is to really reform health care you would have to break the back of some pretty strong interest groups that help both political parties. Lawyers, drug companies, insurance companies, Doctors, Nurses Unions, Hospital administrators and so forth. All would have to make less money of we are going to reform health care, and no on will voluntarily do that.

    Like/Dislike this comment: Thumb up 4 Thumb down 0

  36. JDM says:

    zeke: health savings accounts “work” because of Milton Friedman’s four ways to spend money.

    Way #4, worst way, spend someone else’s money on someone else. That is the current way our government money is spend on health care.

    Way #1, best way, spend your own money on yourself. That is what health savings accounts are.

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  37. Peter Hahn says:

    JDM – think it through. #4 is correct, it is someone else’s money, but it is also private insurance not “government money”.

    #1 – You are not going to make medical decisions about your own health, and you surely arent going to cheap if you could make those decisions. And if you did make those decisions, they would be bad ones.

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  38. Peter Hahn says:

    In this particular case, the government insurance (medicaid) is so little that it doesn’t cover the cost of care at an average institution. That doesn’t bring down the cost of care, it just means that poor patients are going to be shifted to worse and worse facilities.

    The private company buying Horace-Nye plans to be better at billing the state for medicaid benefits. That is, part of their management expertise that they bring to the institution is the ability to extract more money from the state. They can also probably get maintenance work done for less. But at some point they will also have to turn medicaid patients away if we continue to cut medicaid benefits (or not keep up with inflation).

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  39. Paul says:

    “Tort reform can reduce malpractice insurance costs which used to be a pretty big component – maybe 10% – of health care.”

    I think the bigger issue isn’t actual malpractice but the fact that many unnecessary tests and procedures are being done because of the fear of a lawsuit. For example I am sure that many doctors will continue to order PSA tests even though there is definitive proof that they have no positive effect (quite the opposite from a cost perspective). If they have a patient get prostate cancer they probably will be sued if they did not order a PSA test.

    Also, malpractice insurance (especially in certain fields like pediatrics where you want lots of preventative care and we need more doctors) is very expensive. So there you have other problems that can be addressed with tort reform that have nothing to do with cost today.

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  40. Peter Hahn says:

    Paul – what you say is true, but the doctors are still going to have to order the PSA tests even if malpractice is limited. They will still get sued if a patient gets prostate cancer, and lose. Try telling your primary care physician you don’t want a PSA test (I did). Its not just that they (the PSA tests) are useless, they cause harm. The doctors know this but they order them anyway unless you absolutely refuse.

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  41. Larry says:

    No tears here for the poor doctors and all they have to go through. Nobody forced them to follow that career path. All the crying about the high cost of education, malpractice insurance, stress, etc., is just that: crying. Don’t buy in to the self-serving rhetoric the AMA puts out. They are at the heart of the problem.

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  42. Peter Hahn says:

    This has nothing to do with nursing homes, but the PSA test is a great example of what is wrong with the American system. The PSA test will result in 10% of American men getting unnecessary (and with nasty side-effects) prostatectomies at a cost of $25K each.

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  43. Paul says:

    Peter,

    It sounds as if there maybe even more chance of being sued for malpractice if a physician orders and follows a patient based on PSA testing so maybe they will figure that out and start listening to you.

    If you limit settlements to 500K doctors and their insurance companies don’t have to worry about anything. Bad news for the legal industry good news for doctors and patients.

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  44. Walker says:

    “…good news for … patients.”

    Unless, of course, you are left unable to support yourself and your family as a result of medical malpractice. Let’s say you’re young with 40 or more years of work ahead of you at $50,000 per year. That would leave you $2 million in the hole, without even talking about pain and suffering.

    The problem with medical malpractice is juries, plus the occasional real medical nightmare. Why should the damages in the rare horrendous case be limited because too many juries are too generous in average cases?

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  45. Peter Hahn says:

    Paul – there is whats called “standard of care”, which means what most physicians do in your region. If most offer the PSA test and you don’t – even if doing so is not in your patients best interest – you can be sued and you will lose. Even if the limit is 500K you will still be sued and you will still lose. At the trial, they will bring in a bunch of urologists who claim (correctly) that giving the PSA test is always done. Claiming it is bad medicine (and substantiating that claim with loads of clinical trials data) won’t win the day.

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  46. Paul says:

    I guess it is too bad the “standard of care” is contrary to the science. Thanks for the info.

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  47. Paul says:

    Peter, my point above was that if the PSA test causes more harm than good you should eventually have more lawsuits based on doing the test than on the case you describe where they didn’t do it. In those cases you can use the FDA data to show that it should not have been done. Either way the lawyers have a merry Christmas! In all cases the cost gets passed on eventually to the rest of us and HC costs continue to rise.

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  48. Peter Hahn says:

    Paul – thats the advantage of “standard of care”. As long as it is accepted practice, it isn’t malpractice.

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  49. JDM says:

    Peter Hahn “You are not going to make medical decisions about your own health”

    No, you are going to make market decisions. Best service at the best price.

    We do that in shopping for car insurance. Geico competes with Nationwide, why? because in that industry, market forces still dictate service and price.

    If we put market forces back into health care, we will solve a lot of the current problems.

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  50. Paul says:

    Peter, I understand that. I am just saying that the “standard of care” appears to fly in the face of the science. Too bad.

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