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.
Tags: adirondacks, analysis, economy, health, politics
“…you are going to make market decisions. Best service at the best price.”
But when it comes to medical matters, how do you know what the “best service” is? And have you ever tried to get an exact price on an operation in advance? I tried once, without success at all– the actual price turned out to be more than double the estimate. And of course they won’t operate until you’ve signed all those guarantees to pay they’re so fond of these days. Besides, if you have health insurance, you don’t care how much it costs– you just want the best.
An effective market is based on transparent and complete information, conditions that simply don’t apply in the world of medicine.
JDM – you can go out and try to buy cheaper insurance – or your employer can. presumably they do that already. But the insurance companies cant tell the doctors how to prescribe medicine either. They try to save money by not paying the doctors if some form isnt filled out perfectly.
We have gotten off track. What are we going to do about these older poor people that maybe are going to get kicked out into the street? I am not as market crazy as Walker would like to think. There is room for (and a market for) private for-profit entities here (it looks like it is pretty big business). But I think that we also need to have private not-for-profit facilities that can care for the people that cannot afford these other higher end places. All of these places can exist together it isn’t an and/or question. My aunt was a Dominican sister of the sick poor that went to poor people homes (mostly in the inner city) and helped care for these kinds of folks. Too bad we don’t have more people nowadays that have this kind of calling.
Some folks need to be in a “home” but I also think that many people can stay in their homes much longer than they are. It may make their lives shorter but many would prefer a shorter life at THEIR home than a longer one in a “home”. This is the case for my parents. But with that said it is a lot of work. I think that many family members these days don’t try hard enough to care for their aging parents. I also know that many many do (and eventually they have no choice) so don’t jump all over me if that is you.
Walker: “Besides, if you have health insurance, you don’t care how much it costs– you just want the best.”
Aye. There’s the rub.
There will have to be several things that happen together in order to restore market forces into the health care system.
The list of three things I presented earlier in this thread represent a very rough outline (and there are more bullet items beyond those three) that need to be addressed, pretty much simultaneously, in order to get us heading in the right direction.
“It may make their lives shorter but many would prefer a shorter life at THEIR home than a longer one in a “home”.”
Amen to that! (Spoken as a devout atheist.) As I get nearer to the time when it could be me lying helpless in some hospital bed the beneficiary/victim of the full armamentarium of modern medicine, I can only hope that I hang onto my mental facilities and power of speech sufficiently to be able to refuse treatment. Maybe I’ll be sufficiently ambulatory that I’ll be able to find a nice hole in the ice somewhere when the time draws nigh. Anything is better than having one’s “life” extended indefinitely at vast expense to one’s loved ones when all quality of life is gone.
JDM, you want to do away with health insurance? How? Make it illegal?
And if you could somehow make insurance go away, and even if you could cut the cost of medical care in half, you’d still be left with the possibility of absolutely ruinous medical bills.
Besides, consider that people still find auto accident insurance a reasonable thing to spend money on, even though repair costs aren’t ruinous. And auto body shops charge reasonable amounts. I think the difference has everything to do with how utterly important health is. Take your car to a bad body shop, and you might regret your choice briefly. Take your body to a quack and you can regret your choice for the rest of your life.
I don’t think market forces work as well in matters where the prospects of making a bad choice are so extreme.
“I can only hope that I hang onto my mental facilities and power of speech sufficiently to be able to refuse treatment.”
Walker, you should make sure you have a living will that includes things like an “advanced directive”. I hope I won’t need it for a while (I am riding my bike home from work so you never know!) but I have had one for years.
If you saw the (excellent) George Clooney movie recently, The Descendants, they have a great example of how one works. You will see that his wife’s family doesn’t have a choice when it is time to shut things off, she spoke for herself before she had the accident and couldn’t communicate anymore (If you haven’t seen it I don’t want to give anything else away!)
I didn’t mean to be a troll upthread, and was not insulting anyone in particular, Paul, especially not you, but this issue really turns into banal talking points quickly, and I think it’s because there’s a decided lack of information out there on health care. I think it’s because until it hits you in the face, with a relative about to be thrown out of a nursing home, or a condition that doctors won’t treat, or a clown act that springs up as a result of doctors, hospitals and insurance companies never being on the same page, this stuff about premiums and cost curves and which agency is responsible for what is dreadfully complicated and boring.
When it does hit you in the face, it’s impossible to understand.
I agree with Mervel: We need to ask questions. I also agree with my first statement–very few people have any answers. And this stuff is too serious for the regular red-blue boilerplate.
A good post, though, Brian.
Walker: I don’t recall saying anything near wanting to do away with health insurance. I want to see market forces reintroduced into the process, along with tort reform, and mandate reform.
There are choices in health care besides competence and quackery.
Some people prefer chiropractic treatment, some natural treatment, some want all the gismos, some want a competent doctor with fewer gismos.
Once market forces are back in the system, the number of services will increase and the price will decrease. Always does.
“I don’t recall saying anything near wanting to do away with health insurance.”
I’m sorry, JDM, you didn’t say that. But how do you have market forces at work if no one has to worry about the cost of treatment because insurance is covering it? Cost is one of the two main drivers of the market.
Walker: “But how do you have market forces at work”
You introduce health savings plans. But that is only a single step of a many-step, many-faceted plan.
JDM how do health savings drive down costs?
with regard to tort reform, I agree that looking at medical science and not standard of care offered by other doctors would be a more accurate way of determining malpractice. “Standard of care” seems to lead to two odd conclusions: bad medicine is alright so long as a majority of doctors engage in its and good medicine is malpractice if only a minority of doctors practice it. Though perhaps there is a concern that juries would be confused by overly technical testimony regarding medical science.
An NCPR audio report about Horace Nye indicated that about 100 patients were cared for at the nursing home. If the low end of the estimated $2-3 million per year loss is considered true that means each patient’s costs of care exceed $20,000 per year and if the high estimate is true that means in excess of $30,000 per year. How much does the average patient contribute to his/her care from out of pocket, medicare, medicaid or family contributions? What are we talking $50-60,000 per year per patient? I don’t know about the rest of you but as a retired widower I live on a hell of a lot less than any of these estimates I have offered up. 135 employees to care for 100 patients are we sure they are not confusing this place with a minimum security prison?
For those who think the medical system is NOT as rigged as politics I beg to differ. Back in Sept 94 I slid off rain slicked roof sheathing, in MD, and tore up the rotator cuff in my left arm. In Jan 95 I finally got it repaired. I had and still have Blue Cross Blue Shield (plus medicare now) but more than a month was spent trying to heal my arm with PT before they would pay for an MRI so as to enable the surgeon to ascertain the damages. Four months later the shoulder was repaired and BC/BS sent me a little note to try and help them keep costs down by alerting them of any waste and fraud that I might discover. Copies of the cost of my care were sent to me and I dutifully went through them and pointed out that they had been billed by the first hospital that I did not have the surgery accomplished at because my surgeon cancelled surgery when he thought I had a cancerous growth in my abdomen, and they did not pay that hospital; very good, right? Upon closer inspection I observe that $2000 had been billed for two suture anchors. My little engineers brain said what the hell could a suture anchor consist of, an autoclaved stainless steel miniature screw eye that is screwed into bone so as to provide a place for the surgeon to anchor muscle and tendon torn asunder? Wrong! Upon investigation I discovered a suture anchor was a piece of SS rod about 1/2 inch long 1/8 inch diameter with one end split and a length of suture crimped into the split end, a hole is drilled into bone and suture anchor is driven into hole with hammer and punch; a $1000 each I went ballistic. First I went to the hospital to give them a chance to rectify the pricing, nope that was the correct price as far as they were concerned. I was incredulous $1000 for 10 cents, no I’ll go whole hog 25 cents worth of material. I called BC/BS and told them what I had discovered and advised them to refuse to pay, too late they had already paid the hospital and that $1000 per suture anchor that was the going rate, no problem. Had I not had insurance the total cost billed for my rotator cuff repair would have exceeded $30,000 but because I was a good little boy and used the PP list to select my surgeon and hospital the $30K+ was whittled back to about $14K, and doctors are complaining about medicare/medicaid?
Currently medicare is my primary insurance and BC/BS is secondary so they are on the hook only for the difference between what they would pay in excess of what medicare pays which is usually only a few percent. Full circle to my original question, how can Horace Nye or any other nursing home be losing $20-30K per patient per year while the patients are covered under either medicare or medicaid? Are they charging hospital rates $100 per aspirin, slipping in a $1000 suture anchor when patients are not looking?
I reckon market forces account for the 400,000% markup on the retail price of those suture anchors, eh? ((1000/0.25)=4000*100=400,000%)
My grandparents spent their last days in a nursing home. They were both physically healthy until a fairly old age. They worked hard and saved money and were financially stable with a nice home. My grandfather lived to be 90 and had some issues with small strokes in his final years that caused some memory loss. We could have managed his problems at home.
My grandmother was about 6 years younger had alzheimers. Before we knew she was having serious issues (because she hid her problems for a long time) she cancelled the health insurance they had carried, the health insurance that would have paid for much of the care they eventually needed.
My parents tried to take care of them in their own home for a while but it wasn’t a safe environment for an alzheimer patient. They found a nursing home that would take both of them. The costs quickly exhausted all of my grandparents’ savings, their house and all their assets were sold and they died broke. If it weren’t for Medicaid my parents would have probably had to sell their home too to pay for the nursing home.
My grandfather had enough of living in the home and he stopped eating. My grandmother’s mental faculties were too long gone by that point. Her body kept on for years after her mind checked out.
They were both life-long Republicans. Thank you FDR for the Social Safety Net.
Peter Hahn: “JDM how do health savings drive down costs?”
I’m very careful in all remarks to indicate that I believe this is one of many steps that must be taken, and will not achieve much on its own.
Taken together, introducing market forces into the health care system will cause innovation and such things as “find the need, fill the need” services to expand.
People with health savings plans will have the ability to choose among a variety of services (not competence and quackery, as I pointed out in a previous post), allowing for innovative service providers to find better and less expensive means to provide the same excellent quality health services.
JDM, who is going to pay the claims after all of your reforms are in place?
People will say that we “can’t afford” nursing homes. This is FALSE. We spend zillions of dollars in corporate welfare to destroy and “rebuild” foreign countries like Afghanistan and Iraq rather than in helping our own citizens. It’s a lie to say we can’t afford nursing homes. Let’s tell the truth. We CHOOSE not to afford them.
Walker:
Insurance is for unforeseen and usually large expenses.
How much would you expect for car insurance if it covered every oil change?
Some people pay over $10,000 per year out-of-pocket health care premiums for family coverage (not counting the $12,000 their employer also pays for them).
How about paying $2,000 in premiums ($10,000 deductible) and up to $10,000 on your own? You employer then gives you a $12,000 raise to boot (because they pay nada on their part). You end up paying less, making more, and if you stay healthy, you only barely touch your deductible.
make that “unusually large expenses”
JDM – the only way to get market forces to work in health care is to have the tax payers pay directly like in a single payer. That’s why those systems are so much cheaper. This is hard for you to grasp I know.
My dead grandparents thank you for the thumbs down. Classy.
No normal people can actually afford nursing care for very long. I would bet probably 10% of the people in the North Country could actually go to a Nursing home and afford to pay out their own pockets to stay there for four or five years.
It will always have government involvement, because a just society will always at some level take care of the most vulnerable,\; babies, children, the sick, and the disabled and the very old. If we stop doing that we are doomed anyway.
It’s long overdue to accept that government can no longer be our health care and nursing home providers, with the baby boomers fast approaching obsolesence, we have to acknowledge these grim realities, and the ugly consequences that will come with them, we waste great disproportionate sums of monies keeping old people alive for very short periods of time, doctors are a major problem by their defensive medical practices, people have to accept that for most aging people in this country long term care will not be possible except for over crowding hospitals that must take them in admission.
In my opinion some of the problem is that the history of medicine has erroneously convinced the public, or at least people afraid to die, that one more proceedure, one little pill, will cure any and all medical ills. The cycle of life is to reach maturity after which there is a natural decline that leads to death. Death is inevitable. Big Medicine has only reacted to what J.Q. Public wants…to stay alive at all costs. I am not saying we give up on life but rather as individuals and as society we look again at what we want. A life lived with quality.
Long term care is necessary for many people. We should provide the long term beds for those who need it. Some people in nursing homes don’t need to be taking up the beds because they really are able to live at home or in an institution that gives less direct help. There are agencies that help people “age” in their own homes. It is somewhat of a new paradigm so not many folks are aware of it.
As someone said earlier, the system is broken. Those who work in healthcare, those who have to interface between the public and the government (the state and federal folks who mandate out the wazoo but who also seek to protect the public) have known for a long time the system is broken, especially for our poor elderly. It seems to be just now that the communities are aware. Where were you before? Our elderly, at least most of them, have made our country what it is and they deserve to be taken care of. There are no simple solutions for this extremely complex and emotional issue.
There are vastly fewer people today who go to nursing homes than 30 years ago.
I think that is part of the problem also, nursing homes are used by less and less people who can afford limited care or other types of care, so nursing homes end up with people who cannot afford those other options.