INTRODUCTORY REPORT AND SUPPORTING PAPERS Despite the plan to divide the subject matter of this study into an introductory report and supporting papers, an early statement on the extent of major findings is needed for an informed impression of the magnitude and substance of the entire effort. That summary follows. MAJOR FINDINGS* NURSING HOME CARE IN THE UNITED STATES: (Introductory Report) Medicaid now pays about 50 percent of the Nation's more than $7.5 billion nursing home bill, and Medicare pays another 3 percent. Thus, more than $1 of every $2 in nursing home revenues is publicly financed.1 There are now more nursing home beds (1.2 million) in the United States today than general and surgical hospital beds (1 million). In 1972, for the first time, Medicaid expenditures for nursing home care exceeded payments for surgical and general hospitals: 34 percent as compared to 31 percent for hospitals. Medicaid is essential for growing numbers of elderly, particularly since Medicare nursing home benefits have dropped sharply since 1969. Average Social Security benefits for a retired couple now amount to $310 a month compared to the average nursing home cost of $600. Medicaid (a welfare program) must be called upon to make up the difference. The growth of the industry has been impressive. Between 1960 and 1970, nursing home facilities increased by 140 percent, beds by 232 percent, patients by 210 percent, employees by 405 percent, and expenditures for care by 465 percent. Measured from 1960 through 1974, expenditures increased 1,400 percent. 1 The Committee's Introductory Report, as released on November 19, 1974, incorporating the latest statistics from HEW reported that total revenues for the nursing home industry in 1972 were $3.2 billion and $3.7 billion for 1973. Subsequent to publication of this report the Social Security Administration released new estimates for 1974. Total expenditures are estimated at $7.5 billion. This change reflects spending for the Intermediate Care program, which until recently was a cash grant program to old age assistance recipients. With its change to a vendor payments program such expenses are properly countable as nursing home expenditures. Consequently, changes were made in this report. For complete details, see appendix 10. *For recommendations, see p. 109, this Report and each "SUPPORTING PAPER." Despite the heavy Federal commitment to long-term care, a coherent policy on goals and methods has yet to be shaped. Thousands of seniors go without the care they need. Others are in facilities inappropriate to their needs. Perhaps most unfortunate, institutionalization could have been postponed or prevented for thousands of current nursing home residents if viable home health care and supportive services existed. Although such alternative forms of care may be more desirable from the standpoint of elderly patients as well as substantially less expensive-the Department of HEW has given only token support for such programs. Despite the sizable commitment in Federal funds, HEW has been reluctant to issue forthright standards to provide patients with minimum protection. Congress in 1972 mandated the merger of Medicare and Medicaid standards, with the retention of the highest standard in every case. However, HEW then watered down the prior standards. Most leading authorities concluded at subcommittee hearings that the new standards are so vague as to defy enforcement. There is no direct Federal enforcement of these and previous Federal standards. Enforcement is left almost entirely to the States. A few do a good job, but most do not. In fact, the enforcement system has been characterized as scandalous, ineffective, and, in some cases, almost nonexistent. The President's program for "nursing home reform" has had only minimal effect since it was first announced in 1971 and actions in 1974 fall far short of a serious effort to regulate the industry. The victims of Federal policy failures have been Americans who are desperately in need of help. The average age of nursing home patients is 82; 95 percent are over 65 and 70 percent are over 70; only 10 percent are married; almost 50 percent have no direct relationship with a close relative. Most can expect to be in a nursing home over 2 years. And most will die in the nursing home. These patients generally have four or more chronic or crippling disabilities. Most national health insurance proposals largely ignore the long-term care needs of older Americans. Immediate action is required by the Congress and executive branch to improve past policies and programs which have been piecemeal, inappropriate, illusory, and shortlived. MAJOR POINTS Supporting Paper No. 1 "THE LITANY OF NURSING HOME ABUSES AND AN EXAMINATION OF THE ROOTS OF CONTROVERSY" Abuses of patients in nursing homes have been well publicized and well documented. And yet they persist, perhaps because of the belief that they are exceptions to the rule. However, subcommittee transcripts are replete with examples of cruelty, negligence, danger from fires, food poisoning, virulent infections, lack of human dignity, callousness and unnecessary regimentation, and kickbacks to nursing home operators from suppliers. Estimates on the number of substandard nursing homes in the United States vary widely, but the overwhelming evidence indicates that a majority of the nursing homes fail to meet standards of acceptability. Nursing home placement often is a bitter confirmation of the fears of a lifetime. Seniors fear change and uncertainty; they fear poor care and abuse; loss of health and mobility; and loss of liberty and human dignity. They also fear exhausting their savings and "going on welfare." To the average older American, nursing homes have become almost synonymous with death and protracted suffering before death. Supporting Paper No. 2 "DRUGS IN NURSING HOMES: MISUSE, HIGH COSTS, AND KICKBACKS" According to most studies, the average nursing home patient takes 4.2 different medications each day. However, more recent studies reveal that the average may be seven medications, or perhaps even higher. Prescriptions for nursing home patients typically total $300 per year, more than three times the cost for the noninstitutionalized elderly. In 1972, drugs accounted for 10 percent of all nursing home expenditures $300 million in all. And yet, the flow of drugs through many of America's 23,000 43-646 O-74-2 nursing homes is largely without controls. It is haphazard; it is inefficient; and it does not help the patient desperately dependent upon others for protection when put in a state of semisleep or outright unconsciousness. Supporting Paper No. 3 "DOCTORS IN NURSING HOMES: THE SHUNNED RESPONSIBILITY” Physicians have, to a large degree, shunned the responsibility for personal attention to nursing home patients. One of the reasons for their lack of concern is inadequate training at schools of medicine. Another is the negative attitude toward care of the chronically ill in this Nation. Medical directors are needed in U.S. nursing homes and will be required in HEW regulations effective January 1976. The subcommittee's May 1974 questionnaire to the 101 U.S. schools of medicine indicates a serious lack of emphasis on geriatrics and long-term care: Eighty-seven percent of the schools indicated that geriatrics was not now a specialty and that they were not contemplating making it one; 74 percent of the schools had no program by which students, interns, or residents could fulfill requirements by working in nursing homes; and 53 percent stated they had no contact at all with the elderly in nursing homes. Supporting Paper No. 4 "NURSES IN NURSING HOMES: THE HEAVY BURDEN (THE RELIANCE ON UNTRAINED AND UNLICENSED PERSONNEL)" Of the 815,000 registered nurses in this Nation, only 56,235 are found in nursing homes, and much of their time is devoted to administrative duties. From 80 to 90 percent of the care is provided by more than 280,000 aides and orderlies, a few of them well trained, but most literally hired off the streets. Most are grossly overworked and paid at, or near, the minimum wage. With such working conditions, it is understandable that their turnover rate is 75 percent a year. One reason for the small number of registered nurses in nursing homes is that present staffing standards are unrealistic. The present Federal standard calls for one registered nurse coverage only on the day shift, 7 days a week, regardless of the size of the nursing home. By comparison, Connecticut requires one registered nurse for each 30 patients on the day shift, one for every 45 in the afternoon; and one each 60 in the evening. A serious national shortage of nurses still persists, despite training programs. Supporting Paper No. 5 "THE CONTINUING CHRONICLE OF NURSING HOME FIRES" In 1971, there were 4,800 nursing home fires; 38 persons were killed in multiple death fires and some 500 more in single death fires. An estimated $3.5 million loss was directly attributable to nursing home fires. Nursing home patients are especially vulnerable to fires. Many are under sedation or bound with restraints. Physical infirmities and confusion often cause resistance to rescue. There is reason to believe the number of nursing homes failing to meet fire safety standards is actually increasing. In 1971, the General Accounting Office reported that 50 percent of U.S. nursing homes were deficient in regard to fire safety. A January 1974 study by the U.S. Office on Nursing Home Affairs said that 59 percent of skilled nursing facilities are certified with deficiencies. HEW spokesmen indicated that in excess of 60 percent of intermediate facilities do not comply with existing standards. The requirements are on the books, but they are not heeded. Even more dramatically, the GAO 1974 study indicates 72 percent of U.S. nursing homes have one or more major fire deficiencies. Supporting Paper No. 6 "WHAT CAN BE DONE IN NURSING HOMES: POSITIVE ASPECTS IN LONG-TERM CARE” It is unjust to condemn the entire nursing home industry. There are many fine homes in America. A growing number of administrators are insisting upon positive approaches to therapy and rehabilitation, innovations in physical structure of the physical plant; employee sensitivity training and cooperative agreements with local schools of nursing; and even self-government and other activities for the patients. "Ombudsmen" programs have been established by Presidential direction and are making some headway. In some States, the nursing home industry has launched an effort to upgrade its facilities by establishing directories, rating systems, and a "peer review" mechanism. These efforts offer the prospect of improving nursing home conditions if conducted in a vigorous and effective manner. In Chicago, nursing homes have a "cool line" telephone number for relatives, visitors, or patients who have complaints. |