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BY ROBIN BIESEN
| Sunday, November 10, 2002 | (No comments posted.)
Times Staff Writer
Indiana ranks near the top when it comes to its abundance of nursing-home beds but near the bottom when it comes to filling them -- a cost of millions of dollars to taxpayers.
The federal government's Administration on Aging ranked Indiana -- with about 787 beds for every 1,000 Hoosiers age 85 and older -- as one of the mostly highly bedded states in the country. Only Louisiana, with 834 beds per 1,000 residents age 85 and above, had more.
Although the trend in many states has been for long-term care facilities to close as social service programs turn their focus away from institutions and toward home- and community-based care, nursing home construction in Indiana has been on the rise. Since 2000, Indiana added three facilities and 500 nursing home beds, an upward tilt that continued through 2002. In August, the state reported it had 495 Medicaid-qualified nursing homes.
The additional capacity occurred at the same time 25 percent of the state's nursing home beds remained empty. Critics of the system argue another 13,000 or more nursing home residents could be treated more effectively and humanely if the state had a broader range of home- and community-based options.
Few Indiana nursing homes have closed. Critics say the industry has flourished because of the state's willingness to subsidize empty beds in a billion-dollar industry and pay more per day to nursing homes that have higher vacancy rates.
In 2001, payments to nursing homes gobbled up nearly 25 percent of the state's annual Medicaid budget.
During the last fiscal year, the state poured more than $800 million into nursing homes to care for about 26,000 older Hoosiers who qualify under the state's Medicaid guidelines, up $33 million from a year earlier.
Detailing a problem
Cindy Collier, director of policy and planning for Indiana's Family and Social Services Department, can tick off Indiana's nursing home statistics without a pause:
* The care of two out of every three nursing home residents in Indiana is paid for by Medicaid.
* While the national nursing home vacancy rate is about 10 percent, Indiana's is 2.5 times that, hovering at about 25 percent.
* If you're older than 65 in Indiana, you are 35 percent more likely to be in a nursing home than you would be if you lived in another state.
* Although nursing home beds are vacant, the waiting lists for those needing home-based health care are overflowing with older Hoosiers who wait months, sometimes years, to get necessary services. By the last count, 27,000 people were on waiting lists for either the CHOICE or one of the various Medicaid waiver programs.
Long criticized for the way the agency allocates its resources, Collier said FSSA along with members of the Commission on Home and Community-Based Care -- an initiative created by Gov. Frank O'Bannon earlier this year to address the cost of providing care to Indiana's oldest residents -- are working together to change what has been Indiana's status quo.
"The nursing home industry is overbuilt. Medicaid is here to help folks, and to subsidize empty nursing home beds is indefensible," Collier said.
"What we are doing now is working on a program that would flip the way dollars are spent. For a long time, the spending has been skewed toward nursing homes."
Following a directive from O'Bannon earlier this year, FSSA began looking at its options. O'Bannon spokesman Andrew Stoner said the governor had taken a look at a system in need of repair.
"The governor believes it is time to take a look at how to balance the system of care for older Hoosiers, including a wider array of options and services for people as they age," Stoner said.
The plan: Lobby for legislative changes to accomplish the goal. Legislation in the works could divert funds away from nursing homes and into community- and home-based services, leaving options for care that may allow seniors to stay at home longer, perhaps permanently. For some seniors already in nursing homes, that would include the option of moving out of an institution with the promise of continuing care.
"It should be that people can stay home if they can," Collier said. "There are people who need support services but who could still stay in their homes, and that should be available to them. Most people, when given the choice, would chose to be more independent."
Collier said the state believes it may be able to help two or three seniors for every person diverted away from a nursing home.
It is a notion that doesn't sit well with many of the for-profit nursing home owners, who see their industry's future hanging in the balance.
Bad news for nursing homes
"We understand FSSA has as a priority community- and home-based care," said Steve Albrecht, director of economic and legislative affairs for the Indiana Health Care Association, an umbrella organization that represents and lobbies for 300 nursing homes and assisted living centers in Indiana.
"We're not opposed to that. We are opposed to the idea that the state would rob Peter to pay Paul."
Albrecht said his organization doesn't buy into the idea that large numbers of seniors currently in nursing homes could be moved into a more independent setting.
"For most residents of nursing homes, the families have already tried to care for them. Their needs became too great to be cared for at home, and that's when they went to a nursing home," Albrecht said.
"We as an organization believe the Medicaid waiver programs are a good idea. It is a mistaken idea, though, to believe that it is less expensive to care for a person in a community- or home-based setting.
"We believe it is important that the state commits to delivering the right care in the right place at the right time," he said. "And for some people, the right place for some people to live is in a nursing home."
Jim Leich, president of the Indiana Association of Homes and Services for the Aging, which represents about 150 not-for-profit nursing homes in the states, said the problem in Indiana today is too few resources to pay for the growing needs of the aging.
Leich said whatever incentive there may have been that spawned growth in nursing-home construction in the 1980s has evaporated. He pointed, as proof, to the most recent data on long-term Medicaid spending that shows Indiana spends less than 30 other states when it comes to payments to nursing home providers and additional Medicaid cuts.
A new round of Medicaid cuts that is being phased in by the state, which came on the heels of Medicare reductions, is going to force a contraction in the Indiana nursing home industry, he said.
"It's not that Indiana is spending too much on nursing homes but that we are not spending enough on home- and community-based services," Leich said.
"That is why we really need to increase the overall pie, not just divide it up differently. Given the state's budget problems, this will be very difficult."
Yet, Albrecht and Leich said the services provided by nursing homes are critical in the care mix for older Hoosiers.
Changing course
John Cardwell, chair of the Indiana Home Care Task Force, agreed proposals for change may be painful for nursing-home owners. Still, he said it is an initiative that is long overdue.
"Our system in Indiana today is increasingly out of sync with other states. Most states have already shifted their public investment more toward home- and community-based services," Cardwell said.
"The reasons for change are straightforward -- the average cost per-person of caring for someone at home is less than caring for someone in an institution. At the same time, most people prefer to be cared for at home."
Cardwell believes there is support for the kind of change needed in Indiana but knows those opposing change have every reason to fight.
"The governor has said we need to invest more in community- and home-based care. He has said we shouldn't be paying for beds in institutions that aren't being used. There is no question there is a problem. The question is: How serious is the O'Bannon administration on fixing the problem," Cardwell said.
"I have been critical of the O'Bannon administration in the past. The nursing-home industry has been very aggressive in putting pressure on the political process because every day, every week, every month we have a system that reimburses them for care that is not needed or for empty beds, that's money for them."
To date, FSSA has been unable to say how much money goes into paying for care and how much Medicaid funding is spent subsidizing the industry.
Collier said the subsidy is built into a per-patient, per-day funding stream that reimburses nursing homes with higher vacancy rates more than they do those that are closer to being full.
Albrecht and Leich said if such subsidies existed, they are long gone, replaced most recently with a plan to penalize nursing homes that are less than 65-percent occupied.
But, Sen. Rose Ann Antich, D-Merrillville, and a member of the state's Medicaid Oversight Committee, said after much prodding, FSSA representatives finally admitted earlier this year that nursing homes were being paid for certified beds, whether or not they were occupied.
"There is no question Indiana has been subsidizing empty nursing home beds. When questioned by the Medicaid Oversight Committee, FSSA tried to avoid the question but eventually they said that they could not give an exact cost figure on how much the state paid for empty beds, because it was intermingled with other costs," Antich said.
Beyond stopping the subsidies, Antich said she believes the state has an opportunity to move in a new direction that will mean positive changes for those who are aging in Indiana.
She knows there will be those opposed to change.
"There will be a strong movement by lobbyists on this issue, but I don't think there is a lobbyist in the world that can convince me that it wouldn't be better for people to live at home," she said.
"This isn't going to save us money, but it is going to allow us to redirect our spending in a more positive way. This is one initiative of the governor's that I would never argue with -- the idea that people can live better, longer and healthier given help at home."
Robin Biesen can be reached at biesen@nwitimes.com or (219) 933-4168.
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