By: David A. Smith
[Continued from yesterday’s Part 1.]
Slowly he turned away from the railing and headed for the administration building. And for one brain-wrenching moment he felt a sudden fear-an unreasonable and embarrassing fear of that stretch of concrete that formed the ramp. A fear that left him shaking mentally as he drove his feet towards the waiting door.
– Clifford D. Simak, Huddling Place, 1952
In yesterday’s Part 1 of what has expanded into a five-part post (that has taken me a couple of weeks to read enough to fill in the chasm of my ignorance on the topic), we discovered that new regulations covering Medicare/ Medicaid-reimbursed nursing homes (nearly all of them) are the first updates in a quarter of a century.
It was so long ago he wasn’t married to a Czech
Sources used in this post
And that fact sent me back into the Google-archives to discover that like funeral homes, about which I posted at length, nursing homes are a residential modality from a time before – pioneered in Post-WW2 urban diaspora where the automobile enabled substantially greater inter-generational mobility, and as the Boomers’ parents fled the city for the suburbs, they left their elderly behind, giving rise in 1946 to the enactment of the Hill-Burton Medical Facilities Survey and Construction Act.
AHI multi-part posts on unusual emerging housing tenures
May 18, 2009: Outlaw in-laws (accessory dwelling units, 2 parts)
January 6, 2016: Sprouting innovation (co-living; 3 parts)
“The most comprehensive hospital and public health construction program ever undertaken,” Hill-Burton authorized the creation of ‘health centers and mandated that states develop plans for creating enough beds to provide a continuum of care (I am paraphrasing into modern terminology).
The impetus for Hill-Burton
By 1954 the regulated nursing home had emerged as an asset class, one that got a huge boost with the next game-changer, a part of LBJ’s Great Society:
Bringing America up from rural poverty, one handshake at a time: Appalachia, 1964
In 1965, the passage of Medicare and Medicaid provided additional impetus to the growth of the nursing-home industry, which, while it had been increasingly steadily since the passage of Social Security, grew dramatically. Between 1960 and 1976, the number of nursing homes grew by 140%, nursing-home beds increased by 302%, and the revenues received by the industry rose 2,000%.
Twenty-fold revenue growth is an explosion. Medicare/ Medicaid, created the nursing home business out of nothing, and that business needed new facilities that were neither hospital nor apartment (as evidenced by the curious concatenation of calling the place a ‘home’ but its residents ‘patients’), and the results was a building boom:
To a great extent, this growth was stimulated by private industry. By 1979, despite the ability of government homes to provide care, 79% of all institutionalized elderly persons resided in commercially run homes.
Booms often lead to excess – especially when, as here, the customers lack either choice (shortage of nursing home beds) or the capacity to make better choices (because they’re failing and the government is paying):
What you could look forward to: Foothill Acres Nursing Home, Neshanic, NJ, 1965
According to investigations of the industry in the 1970s, many of these institutions provided substandard care. Lacking the required medical care, food, and attendants, they were labeled “warehouses” for the old and “junkyards” for the dying by numerous critics. The majority of them, proclaimed Representative David Pryor in his attempt to initiate legislative reform in 1970, were “halfway houses between society and the cemetery” (Butler, p. 263).
Note desk plate: Arkansas Comes First
And, like the almshouses of old, people feared ending their days in the wards of these institutions and relatives felt guilty for abandoning their elders to nursing-home care.
Though the full history of nursing homes is a topic for another future investigative post when I find the right starting material (which might be this, but first I have to read it), in the 1980s nursing homes went through a consolidation (likely paralleling the consolidation of hospitals) as they became vassals of Medicare and Medicaid, and shortly thereafter, HHS issued the regulations that now, a quarter of a century later, have finally been updated.
The regulatory update was absurdly overdue.
In the last quarter century alone, American life expectancy has lengthened two or three years. Hundreds of new life-extending pharmaceuticals have been invented. The Web has revolutionized remote monitoring:
Cybex-Humac, 1981: it looked cool at the time
Microsurgery has become commonplace. And I’m sure that I’m overlooking scores more innovations.
What the heck are those buttons, anyhow?
An ever-bigger bite
Along the way, nursing homes have become a $155 billion industry, housing over 1,400,000 very elderly people whose arc of independence has fallen and continues to decline.
[The revised rules] emerged from a four-year process involving many meetings and almost 10,000 comments from interested parties.
Amending Federal regulations is a process that itself is governed by a statute – the Administrative Procedures Act – and its regulations, and as you might expect the APA emphasizes public hearing, public comment (both verbal and written), and structured written responses to comments. Further, when Medicare/ Medicaid pay a nursing home owner/ operator, the regulations have to protect two constituency who are not present to protect themselves:
1. The nursing home residents (whom the industry insists on calling “patients,” a term that is itself demeaning with its overtones of dependency and illness).
2. Taxpayers, who are ultimately writing the checks.
In view of the billions at stake and the helplessness of both nursing home residents and taxpayers to [protect themselves against nursing home abuse, four years from initial overhaul notice to their new effective date seems if not speedy then at least reasonable.
Will the new requirements help improve care for the country’s 1.4 million nursing home residents?
Age is not an illness, though the medical system treats it like one.
Nursing homes should be homes before they are anything else, including nursing stations, and there should be oriented around five great principles of effective markets: freedom, choice, security, quality, and redress.
[Continued tomorrow in Part 3.]