Balancing Money and Mission
The March 11th edition of USA TODAY carried a front page article with the title “Dying for Care.” The article reported their study of deaths in nursing home patients from COVID 19 with the finding that a health care chain operating facilities in Indiana, Michigan, Ohio, and Kentucky had a much higher than death rate than similar large chains operating in those states. In fact, last winter their death rate was twice the national average. When the data were shared with the company, their response was to reclassify some of the deaths as non-COVID related, but their relative ranking did not change.
In the article, the authors state two observations they consider important.
“Until now, such pervasive failure escaped notice. In a first-of-its-kind analysis, USA TODAY has revealed ownership webs invisible to consumers. Problems across chains eluded federal officials overseeing nursing homes who were focused on individual facilities during the pandemic.”
It turns out their investigation showed Trilogy was owned and operated by a real estate investment trust, (REIT), as opposed to the usual model where the REIT just owns the real estate and collects rent, leaving operation of the facilities to others.
“Nursing homes looking to boost profits have limited options. The business is heavily subsidized by government-funded health care programs for seniors and people with disabilities. One approach is cutting staff costs, typically half of the operating budget in nursing homes…”
They present data showing Trilogy had cut staffing costs 23% over four years compared to a national average of 2%, with cuts falling heavily on the certified nursing assistants. As a result, patients were getting about two hours of direct care per patient per day, compared to a recommended three hours per patient prior to the pandemic. Naturally, they blame this staff shortage for the excessive COVID death rate. They also note the owning REIT is touting its financial success and plans an initial public offering of stock.
Now I have no particular insight into this company, but several observations seem worth noting. First, staffing at nursing homes has been problematic for years. No matter how hard the marketing department tries to obscure the facts, most of the patients are frail, many are incompetent, and none can really be expected to get better. The goal is usually to avoid bedsores and falls, both of which depend on bedside care almost exclusively. As one patient put it to me, “being in a nursing home is being in God’s waiting room.”
Second, most of the patient’s family members feel bad that their loved one is in such a place. Some spouses made promises that they would not put their loved one there, but the realities of 24 hour care for a patient who is not able to engage in self-care intrude. As I have told many families, we do what we have to do to keep the patient safe, which means we need to recognize the limits of what families can actually do, but we also need to recognize the limits of what nursing homes can do.
As it happens, two of my friends worked for a period as nursing home administrators. Both tell stories of terrible abuse of staff by families taking out their distress on the bystanders and demanding miracles with no understanding of the real limitations of what can be done. Unrealistic expectations, or perhaps denial, place additional stress on the system.
So, we have a perfect storm. Patients are challenging. Family members are experiencing remorse and regret. The plaintiffs’ attorneys run advertisements alleging rampant neglect and abuse. “Consumer advocates” recommend constant vigilance to insure proper care. And the government attempts to assure quality by detailed listings of individual deficiencies. Consequently, most nursing homes I know stay out of trouble only if they can keep enough of those staffers I call angels—people who have made it their mission in life to provide love and care to the sick and dying. Unfortunately, the rest may include those who cannot maintain employment elsewhere.
Whether nursing homes are for profit or non-profit, they all have to maintain an operating margin. “Business efficiency” always runs the risk of cutting staffing too much, or cutting the wrong staff, with increased injury to patients. In the United States we worship the free enterprise system, but may not really mean it. As one family member put it about Trilogy, “The are making money off people’s lives.” But having staff means paying wages, and the money has to come from somewhere. And the widespread employment issues suggested in the phrase “the great resignation,” have come the healthcare, too. There may simply be no one in the pipeline to replace those who quit.
I don’t want to imply that more money alone would solve the problems, because I am convinced you can’t pay people enough to put up with difficult situations indefinitely. For too long, US businesses have treated employees as fungible, and that attitude infests medicine, too. But care systems are more dependent upon the internal motivations of the employee than the usual commercial organizations. Increasing pay, the usual solution to shortages, can make staffing worse in a reimbursement constrained environment and the cost of inflation cannot be passed to consumers as a surcharge.
As illustrated by this story, and by others I have recounted previously, our challenge remains how to balance money and mission. A simple commercial transactional model does not suffice.
14 March 2022
 Stein L, Fraser J, Penzenstadler N, Kelley Lowenstein J. Dying for Care. USA TODAY, Friday, 11 March 2022, p. A1.
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