Seniors Can't Go Home Again
Medi-Cal rules force state's elderly into costly nursing facilities
Vicki Haddock, Insight Staff Writer

Sunday, August 1, 2004

There is no place like home -- but the places we euphemistically call "nursing
homes" don't even come close. Metal hospital cots two to three to a room, hallways
reflecting the flicker of fluorescent tubes, uniformed nurses, intercom pages, and
the air laced with the odor of disinfectant, sterilizing the place in every sense of the
word.

But the most confounding reality about nursing homes is this: In a counterproductive
effort to save money, the state of California continues to force into nursing homes
people who don't even need to be there.

A startling number of nursing home patients -- the state's Little Hoover Commission
conservatively pegged it at one third, or more than 20,000 Californians -- could
thrive in a more homelike setting.

What's more, they could do so for a fraction of the more than $43,000 per year the
government pays to reimburse nursing homes for each of the vast majority of their
long-term patients who end up on Medicaid.

Most people stricken with, for example, Alzheimer's and Parkinson's disease quickly
burn through their savings accounts footing the high cost of care and, thus
impoverished, end up relying on the joint federal-state funded program Medicaid,
run by California under the name Medi-Cal.

These people need help with bathing, grooming, toiletry and eating. They need
companionship and supervision. What they don't need is round-the-clock skilled
medical care: no intravenous or gastrointestinal tubes, no respirators, no on-call
doctors.

But California channels Medi-Cal money for full-time long-term care almost
exclusively to nursing homes -- the kind of costly "over-care" critics compare to
sticking someone in a body cast for a broken finger.

Now, more than two decades after the federal government approved the idea of
using Medicaid money for less costly options like board-and-care homes or assisted
living apartments -- and after more than 30 states have done so in various ways --
California hasn't yet set up a small "pilot program" to test it in the state.

And many elder care experts warn that the design of the program the state is
considering is badly botched, dooming it to failure.

"It's so important that the state get this right. I'm sick and tired of every day placing
people in nursing homes not because they need to be there but because they're
poor or they've just been made poor," said Jason Bloome of Connections, a
Southern California referral service. "The state has a shot at fixing this, but they're
completely flubbing it up."

As far as Floretta Burrows of Novato is concerned, change is long overdue.

The medical world could do absolutely nothing to reverse or treat the dementia that
was relentlessly erasing her mother's memories, her judgment, her essence.

The family sold their homestead in Grass Valley, exhausted their mother's savings
and then dipped deep into their own to pay for her care at Adobe House, a
Petaluma care home specifically designed for Alzheimer's patients.

With its huge windows, low beds, tastefully muted decor, silk flower arrangements
and expansively landscaped outdoor courtyard, Adobe projected the ambience of
private apartments.

The staff responded flexibly to the unpredictable demands of caring for Alzheimer's
patients. Burrows' mother was even invited to sit in the office during the workday
and move papers around, a soothing pastime simulating her former career as a
secretary.

"She felt as if she belonged there. But as happy as she was, I was very anxious and
always had a lot of nervousness that we were running out of money, " Burrows
recalled. "Running out of money meant going on Medi-Cal, which meant moving
Mom to a nursing home.

"A nursing home is more like a hospital. And my mother always hated hospitals."

Ultimately, their private funds dwindled away. Rather than reimburse Adobe House,
Medi-Cal rules required that Burrows move her mother to a nursing home -- and
would pay more for her to be there, in a facility Burrows describes as dark, dingy,
outmoded, uncomfortable and devoid of any feeling of "home."

Her mother died within six weeks.

She doesn't attribute her mother's deterioration solely to the move, but Burrows
does make the plea that the state give families more of a choice, particularly when
that choice is cheaper than the state's alternative.

The state's population aged 85 and up is expected to triple by the year 2040.
Dementia alone will afflict an estimated 1 in 12 people of age 65 or older, and by
age 85, the number is projected to be 1 in 3. Once dementia is diagnosed, patients
typically linger eight to 10 years.

5 years after report

Five years have passed since the state's Health and Human Services Agency
issued a report that acknowledged, "Long-term care in California traditionally has
been biased toward institutional care using a medical model, largely in response to
the public reimbursement available for institutional care. This tendency can result in
care that is both more restrictive and more expensive than necessary."

A host of research has demonstrated that older people and their families favor
choices that maximize their independence and minimize feelings of
institutionalization. Not surprisingly, they prefer places with porches and pets and
privacy.

Although federal rules technically require Medicaid dollars for elder care go to
nursing homes, states can get around that by applying for a waiver to use the
money for assisted living or residential care.

The only caveat is that expanding the system to cover more options will not be
allowed to increase the overall price tag to Medicaid.

A new survey by the Kaiser Family Foundation notes that the percentage of total
Medicaid long-term care money going to community-based options instead of
nursing homes has doubled in the last decade, to more than 30 percent.

Oregon, for example, uses Medicaid to pay for an array of options, including in-
home aides, assisted living apartments, board-and-care homes and, in the most
severe cases, nursing homes.

California's Legislative Analyst's Office pushed the notion as well, saying the idea
had the potential to generate "significant savings."

The Golden State, however, hasn't budged from its nursing home bias.

It would seem like a no-brainer: Why would California blithely pay more than
$43,000 in Medi-Cal per year to keep someone in a nursing home, but balk at
paying $18,000 or even $30,000 for a board-and-care home or assisted living
apartment?

One answer is fear of the "woodwork" effect. If the state suddenly began paying for
all different kinds of desirable care, this line of reasoning goes, tens of thousands of
people now finding a way to privately pay for in-home or residential care might pop
out of the woodwork ready to let taxpayers pick up their bills.

Fearing an onslaught of new applicants, California legislators opted for a pilot
program to determine whether expanding the choices would drop the per- person
cost but drive up the total tab.

"We've found that just doesn't happen,'' insists Jeff Miller, medical policy analyst for
the Oregon Department of Human Services. "You might postpone a person's need
to go to a nursing home for several years. That doesn't save a little money -- it
saves a lot of money."

Indeed, the number of Medicaid recipients in Oregon nursing homes has dropped
by more than a third since it expanded their options. Today, Medicaid pays for
about 5,000 Oregonians to stay in nursing homes while paying for five times as
many to be cared for in homier settings. Said Miller: "We're serving many more
people now, and they're getting more appropriate care. And it's not costing as much
as nursing homes."

A review by the California Healthcare Foundation found that the real world
experience of states that began covering nursing home alternatives was that those
states saved Medicaid dollars while covering more people.

Pilot project test

Instead of embracing the idea five years ago, California's Legislature agreed only to
a bill by former East Bay Assemblywoman Dion Aroner calling for a pilot project test
with 500 to 1,000 people.

It's taken this long for state officials to even begin "finalizing the application," which
means it will take three to five year before test results are in.

Even more unsettling, a host of people in the trenches of long-term care complain
that the criteria the state health department contemplates using are so wildly
inappropriate it will bar more than 90 percent of board-and-care homes from
participating.

For instance, they say, proposed criteria call for participants to be placed in private
rooms with their own bathrooms -- conditions far more luxurious than even private
paying residents typically can afford.

More preposterously, these rooms also would have their own kitchenettes - - a
danger for dementia patients, who could seriously injure themselves. And if the
proposal sets reimbursement rates much higher than the market rate, the pilot
program can expect little if any taxpayer savings, killing chances for real reform.

Advocacy groups, from the Gray Panthers to the California Assisted Living
Association to the American Parkinson's Disease Association, are disappointed.

"If the waiver is submitted as drafted," wrote Jackie Wynne McGrath, state policy
director for the Alzheimer's Association, "all the years of waiting will be for naught,
and the state will miss an opportunity to test a more cost-effective level of care."

The state official who oversees Medi-Cal, Stan Rosenstein, said the criteria are
merely proposals drafted by a private contractor -- and the state may revise them.

If it's successful, the pilot program will show that covering assisted living care
doesn't cost more money or sacrifice quality of care. "And the key question," said
Rosenstein, "is: Does this indeed avoid placements in nursing homes?"

California is also exploring a program, popularized in Texas, which focuses strictly
on people already in nursing homes. The idea is to move them out to a less
restrictive place, while permitting Medicaid to keep reimbursing their care.

The aim is to avoid enticing new recipients by focusing only on people who are
already costing the taxpayers money in nursing homes. The temptation, of course,
is for families to move their loved ones into nursing homes just long enough to
qualify for Medicaid coverage for cheaper, more appropriate care someplace else.

Advocates doubt California can successfully copy the program, given its
performance thus far.

None of this is to deny nursing homes are the best alternative for many residents --
those who benefit from round-the-clock medical staffing and professional therapists
and dietitians skilled in spotting and treating medical needs that could go
undetected in a homier environment.

But consumers increasingly prefer alternatives, and demand for nursing homes is
dropping. Occupancy rates in the state's 1,400 nursing homes has slipped to 81
percent, despite the fact that the state's senior population is growing so fast.

Private long-term care insurance remains an iffy solution: It's expensive and often
doesn't provide adequate coverage. And a new report by the Employee Benefit
Research Institute forecasts that by 2030, most retirees won't be able to afford to
pay anything for a nursing home stay.

For the majority of California's aging Baby Boomers, the steep cost of long-term
care will rapidly consume their assets. Then Medi-Cal will be it -- and we ignore it at
our peril.

"Right now," said former Assembly member Aroner, "we're promoting people living
longer, but we have no idea how to sustain them."

E-mail Vicki Haddock at [log in to unmask]

San Francisco Chronicle Page E - 1

SOURCE: San Francisco Chronicle
http://tinyurl.com/4mrj8

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