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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 * * * ---------------------------------------------------------------------- To sign-off Parkinsn send a message to: mailto:[log in to unmask] In the body of the message put: signoff parkinsn