State's frailest at risk in cost-driven system
Nursing homes get bonus, despite deficiencies
By CARRIE TEEGARDIN
Atlanta Journal-Constitution Staff Writer
THE BOTTOM LINE
ajc.com Nursing Home Guide
What every nursing home in Georgia spends on its patients; how staffing levels at homes compare; comparison of all nursing homes in your county.
How to use the guide
How we assembled the data
Why nursing homes fail
State's frailest at risk in cost-driven system.
National chains earn poor inspection reports.
Family firm finds profits.
Medicare, chains blame each other for downfall.
Georgia's major players.
Experts say most homes don't have enough workers. So why does Georgia reward the ones that spend less on staffing?
Medicaid pays most of the bills in Georgia, but many homes get more -- sometimes much more -- than others.
Ten ideas on how to provide long-term care for the elderly with compassion and dignity.
Frequently asked questions about nursing homes and long-term care
Links to agencies and organizations
About this project
Baby boomers across Georgia are finding themselves on unfamiliar doorsteps. They're walking into nursing homes, assisted living facilities, even adult day care centers, and they're looking for help.
All too often, they're in a panic. Mom just broke her hip. Dad's Alzheimer's disease took a terrible turn overnight. A 50-something husband's high blood pressure triggered a massive stroke.
And here's the unfortunate truth: The vast majority of consumers seeking a new home for a loved one have no idea what to look for.
They don't know how the system works. They don't know who pays the bills. They know nothing of the fine print in government manuals and corporate policies that determines how the frailest people in Georgia are cared for.
"Nobody tells you the things you need to know," said Wilbertine Gunn, whose mother nearly died in one of the worst nursing homes in Georgia.
In fact, the financial and regulatory forces that shape long-term care in Georgia often stand in the way of providing quality care.
"There are an awful lot of well-meaning people who try to make this system work," said Becky Kurtz, Georgia's long-term care ombudsman, "but ultimately it's a system that doesn't reward good care."
Instead, the system rewards nursing homes that keep their patient care expenses down. To try to save tax dollars, Georgia's Medicaid program each year doles out hundreds of thousands of dollars in bonus payments as an incentive for the homes that spend the least.
Those bonuses are even paid to nursing homes where government inspectors have found residents are in danger. Ansley Pavilion, one of Georgia's worst homes until it closed in December 2000, received incentive payments for keeping staff and other costs low, even while inspectors cited the Midtown Atlanta home for insufficient staff, patient abuse and neglect.
"That is ridiculous," said Toby Edelman, a Washington-based attorney for the Center for Medicare Advocacy, a consumer organization. "How can anybody think this is good public policy?"
Even the industry complains of a system that offers no bonuses to the nursing homes with the best records.
"The incentive is to reduce your costs," said Fred Watson, president of the Georgia Nursing Home Association. "There has never been an incentive that is geared to quality."
State health officials defend the incentive payments. They encourage "prudent buying," not poor care, said Gary Redding, commissioner of Georgia's Department of Community Health. "No system is perfect and resources are not unlimited."
The bonuses are designed to encourage nursing homes to hold costs down for staffing, housekeeping, administration -- even meals. The average Georgia nursing home spends just $4.50 a day on the food used to prepare each resident's meals.
The incentives are the product of a long-term care system that's financed in large part by a welfare program, much like food stamps or public housing. Medicaid, the government's health insurance program for the poor, pays for 80 percent of nursing home stays in Georgia.
That's because health insurance will not pay the bills for a long-term stay in a nursing home. Only a handful of Georgians carry long-term care insurance that will pay this expense, even though the chances are relatively high that they will need care. One in four people who reach the age of 65 can expect to spend at least a year in a nursing home.
"People are just now, as a society, realizing that we don't have coverage for this. They assumed this was all part of health care," Kurtz said.
Low staffing levels
The low staffing that results from limited dollars can have crushing consequences for nursing home residents.
Spending on nurses and nurse's aides -- the key workers providing patient care -- is so low that staffing levels in Georgia are among the lowest in the nation.
An AJC analysis also shows that staffing was so thin at 33 homes last year that they violated Medicaid standards, on average, every day of the year. But the homes have paid no penalty because state regulators have done nothing to enforce the requirement.
Pay for Georgia's nursing home workers is among the worst in the marketplace, even for those with decades of experience. Nurse's aides here make an average of $7.40 an hour, barely above what the average fast-food cook earns.
"We have the lowest-paid, lowest-trained, lowest-educated people doing bedside care," said Watson of the Georgia Nursing Home Association.
Annual turnover among nurse's aides is nearly 100 percent statewide. The overwhelming workload that is commonplace in most Georgia homes explains why many aides don't stick with the job, and why patients frequently don't get even their basic needs met.
State inspection reports show nursing home residents frequently have a hard time getting the attention of the staff.
At one Rome nursing home, a woman with a dialysis appointment told inspectors she waited for an hour for a fresh diaper and a bath. She said eight staff members came to her room, one after another, promising to send help. The aides turned off the woman's call light and left. No help ever arrived. The woman told inspectors she felt ashamed and dirty when she went to her appointment without bathing.
EXCERPT: STATE INSPECTION REPORT
THE TOP 10
The largest companies by percent of all nursing home beds in the United States. Companies in boldface operate in Georgia.
Manor Care, 2.16
Life Care, 1.09
Good Samaritan, 0.88
Source: U.S. Centers for Medicare & Medicaid Services
Federal regulations and state inspectors are supposed to guarantee a minimal level of care even if spending is low. But inspection reports show too many nursing homes still are not following the rules.
The number of homes threatened with closure because of severe violations tripled in Georgia last year. Time after time, those violations reflected a failure to provide the basics -- enough food, the correct medications, the proper treatment of wounds.
At one Clayton County nursing home, a woman dropped from 95 pounds to 84 pounds in just one month last year, according to a state inspection report. Her doctor had prescribed high-calorie milkshakes twice a day to help maintain her weight, but records show she was given only seven shakes during the entire month. And an inspector watched as a staff member carted off the woman's lunch tray, reporting "she had eaten well," after she had taken just two bites. Frustrated family members have filed more and more lawsuits in recent years, resulting in a series of multimillion-dollar judgments against the industry. Nursing home companies argue that the resulting spikes in insurance premiums may drive many of them out of business.
But trial lawyers say the high price of that litigation has achieved what government enforcers could not do.
"We have forced the formula so that providing care the wrong way costs more than providing care the right way," said Steve Vancore, spokesman for Wilkes & McHugh, a Florida law firm that has aggressively pursued nursing home cases.
In Georgia, where for-profit homes dominate the industry, nursing homes have the goal of making money.
But turning a profit in the nursing home business can be difficult. It's a low-tech business where prices are set by economy-minded government programs, not by the marketplace.
"Because of the low margins of the industry, to make really high profits, it tends to attract bad actors," said Nancy Weaver, an analyst at Stephens Inc.
In Georgia, a Journal-Constitution analysis shows that facilities operated by four national chains earn much higher operating margins and poorer inspection records than other nursing homes.
Financial reports show just over half of Georgia nursing homes operate in the black, but gross profits at those homes have increased significantly in the last five years. Numerous changes could explain the trend, including increases in state payments to nursing homes recommended by Gov. Roy Barnes. Nursing home operators have been a major benefactor to Barnes, contributing $1.1 million to his 1998 and 2002 election campaigns.
Critics believe the system needs more accountability. "The big picture is getting quality care for residents," said Steve Lomax, president of a union local that represents nursing home workers. "We need to see that the nursing homes are accountable for the money they receive."
The Bush administration has rejected calls to improve care in nursing homes by establishing mandatory staffing levels. Instead, it has launched a program to give consumers better and more detailed information on how well nursing homes perform.
A federal Web site (www.medicare.gov
) already publishes inspection data for every nursing home in the nation. And a pilot program is putting up even more information about the condition of residents in nursing homes in six states. That project is expected to go nationwide this year.
Beginning today, at ajc.com, the Journal-Constitution offers its own guide to nursing homes in Georgia, containing inspection data available on the federal Web site as well as financial data accessible nowhere else on the Internet. With this guide, consumers can compare nursing homes' spending, staffing and inspection histories.
But some say consumer information alone may not be enough. Better nursing homes often do not have vacancies. So, all too often, consumers have few choices if they want a nursing home near where they live.
"In most cases . . . consumers don't have a lot of choice," said Kurtz, the state's long-term care ombudsman.
For people like Wilbertine Gunn, time is of the essence when choosing a nursing home.
Several years ago, Gunn found herself in a panic when her mother's Alzheimer's disease got out of control.
"I needed to place her," she said. "I was frantic."
Someone recommended Ansley Pavilion. Gunn checked it out and found the facility was clean and the people seemed nice. She felt good about her choice when she moved her mother in. But Gunn barely recognized her mother when she visited one day. She wouldn't get out of her chair, wouldn't talk, wouldn't do anything.
"She was in such a state that we just began to cry," Gunn said.
Gunn said her mother was taken to the hospital and doctors found she was critically ill with a range of medical problems, including malnutrition and kidney failure.
Her mother survived, and Gunn took care of her at home for a while before finding a new nursing home. This time, she became a savvy consumer.
"Nobody likes nursing homes," she said. "But when you have to use them, make sure you place your loved one in a good one, the very best you can find -- not just a place that someone says is good."
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